meeting papers for 12 february 2016

Version 9.2.16 FEBRUARY 2016

AGENDA Held on Friday, 12 February 2016 Boardroom - Capital & Coast DHB

Commencing at 8.30am

HOSPITAL ADVISORY COMMITTEE PUBLIC SECTION

QUORUM is a majority of Committee members, and must include at least one member from each Board and at least one co-opted member from each of the other two sub-regional Boards

Item Action Presenter Min Time Page

1. Procedural Business 5 8:30 – 8:35

1.1 Apologies To Note Bryan Betty 3-6

1.2 Continuous Disclosure

1.2.1 Interest Register

1.2.2 Conflicts of Interest

To Consider Bryan Betty

1.3 Minutes of Previous Meeting To Discuss Bryan Betty 7-12

1.4 Matters Arising To Consider Bryan Betty 13

2. DISCUSSION PAPERS

2.1 Operational Services Monthly Report

- Strategic issues and priorities

- Financial performance

- Balanced score card reporting

- Professional Leaders reports

To Note Chris Lowry 30 8:35 – 9:05 14-30

2.2 MHAID Service 3DHB Report To Note Nigel Fairley 10 9:05 – 9:15 31-33

2.3 Quarterly Health & Safety Report - Capital & Coast DHB

To Note Caroline Tilah & Shauna McGuinn

20 9:15 – 9:35 34-37

2.4 Quarterly Quality & Safety Report To Note Caroline Tilah 20 9:35 – 9:55 38-45

3. OTHER

3.1 General 5 9:55 – 10:00

3.2 Resolution to exclude the Public To Approve Bryan Betty 5 10:00 – 10:05 46

CLOSE

PUBLIC Hospital Advisory Committee 12 February 2016 - Agenda

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Item Action Presenter Min Time Page

DATE OF NEXT MEETING

8 April 2016 | Capital & Coast District Health Board, Boardroom

APPENDICES

2.1.1 Excerpt from the Health Needs Assessment 47-52

2.1.2 Mock-up of New Ward (6 East) Build Project 53

2.1.3 CCDHB Monthly Balanced Scorecard 54

2.2.1 MHAID Service 3DHB Balanced Scorecard 55-65

2.2.2 Provisional Suspected Suicide deaths by DHB Region between 2012 and 2015 66-72

2.4.1 Patient Experience Report 73-74

2.4.2 Quality Accounts 75-76

2.4.3 Certification Audit Report 77-82

2.4.4 CCHDB Clinical Measures 83-89

2.4.5 Patient Safety Week Wrap Up 90

PUBLIC Hospital Advisory Committee 12 February 2016 - Agenda

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PROCEDURAL

Wairarapa, Hutt Valley and Capital & Coast District Health Board LAST UPDATED AUGUST 2015

CAPITAL & COAST DISTRICT HEALTH BOARDS

HOSPITAL ADVISORY COMMITTEES

Interest Register

12 FEBRUARY 2016

Name Interest

Dr Bryan BettyChairperson

∑ General Practitioner, Porirua Union & Community Health∑ Chair, Porirua Kids Group∑ Deputy Chair, Wellhealth Trust PHO∑ Chair, CCDHB ICC (Alliancing) leadership group∑ Member, CCDHB Diabetes network∑ Board member, Porirua Union & Community Health Services∑ Deputy Medical Director, PHARMAC

Dr Virginia HopeMember

∑ Chair, Capital & Coast District Health Board∑ Chair, Hutt Valley District Health Board∑ Deputy Chair, 3 DHB CPHAC/DSAC committee∑ Chair, 3 DHB Hospital Advisory Committee∑ Member, Finance Risk & Audit Committees, Hutt Valley and Capital & Coast

District Health Board∑ Medical Director, Institute of Environmental Science & Research∑ Director & Shareholder, Jacaranda Limited∑ Fellow, Royal Australasian College of Medical Administrators∑ Fellow and New Zealand Committee Member, Australasian Faculty of Public

Health Medicine∑ Fellow, New Zealand College of Public Health Medicine∑ Member, Territorial Forces Employer Support Council∑ Member, National Roundtable to Strengthen Pathology & Laboratory Services∑ Member, Regional Governance Group, Central Region DHBs∑ Brother and sister work in health sector in the Wairarapa (disability support and

laboratory respectively)∑ Member, Gillies McIndoe Research Institute∑ Member, DHB Shared Services Executive Team (governance/oversight role)

Dr Judith AitkenMember

∑ Member, Capital & Coast District Health Board∑ Member, Finance Risk & Audit Committee, Capital & Coast District Health Board∑ Member, 3 DHB HAC committee∑ Councillor, Greater Wellington Regional Council∑ Chair, Audit, Risk & Assurance Committee, Greater Wellington Regional Council∑ Member, Strategy and Policy Committee, Greater Wellington Regional Council∑ Chair, Parliamentary Sector Advisory Board∑ Trustee, Carter Observatory Trust

Mr David ChoatMember

∑ Member, Capital & Coast District Health Board∑ Member, CCDHB Hospital Advisory Committee∑ Member, 3DHB CPHAC/DSAC committee∑ Partner employed as Solicitor, New Zealand Public Service Association∑ Chief Policy Analyst, Ministry of Education

Mr Nick LeggettMember

∑ Member, Capital & Coast District Health Board

PUBLIC Hospital Advisory Committee 12 February 2016 - Procedural Business

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Capital & Coast District Health Board LAST UPDATED FEBRUARY 2016

∑ Chair, 3DHB CPHAC/DSAC committee∑ Member, CCDHB FRAC committee∑ Member, 3DHB FRAC committee∑ Member, HAC committee∑ Board representative, Sub Regional Pacific Strategic Health Advisory Group∑ Mayor, Porirua City Council∑ Trustee, Telecom Foundation∑ Chairperson, Wellington Regional Emergency Management Committee, Greater

Wellington Regional Council∑ Member, Wellington Regional Transport Committee, Greater Wellington

Regional CouncilDr Leo BuchananMember

∑ Director, Village at the Park Facilities∑ Advisory Trustee of Te Aro Pa Trust engaged in social housing project

development at Evans Bay∑ Kaumātua for the Royal Australian College of Obstetricians and Gynaecologists

Ms Sue KedgleyMember

∑ Member, Capital & Coast District Health Board∑ Member, Wairarapa, Hutt Valley and CCDHB Hospital Advisory Committees∑ Member, Technical Expert Advisory Committee on Natural Health Regulation∑ Member, Greater Wellington Regional Council∑ Member, Consumer New Zealand Board

Dr Margaret WilsherCrown Monitor

∑ Crown Monitor, Capital & Coast District Health Board∑ Chief Medical Officer, Auckland District Health Board∑ Member, National Health Board∑ Member, Capital Investment Committee∑ Member, Hospital Redevelopment Partnership Group∑ Director, New Zealand Health Innovation Hub∑ Independent Physician, Auckland Medical Specialists∑ Honorary Associate Professor, University of Auckland


4

CAPITAL & COAST DISTRICT HEALTH BOARD

Interest Register

EXECUTIVE LEADERSHIP TEAM12 FEBRUARY 2015

Debbie ChinChief Executive Officer

∑ Member, Rotary

∑ Member, HBL FPSC Procurement Steering Group (regional Chief Executive representative)

∑ Member, HBL Shared Services Council (regional Chief Executive representative)

Chris LowryChief Operating Officer

∑ Son employed by Hutt Valley DHB

Donna HickeyDirector, Human Resources, 3DHB

∑ Sister is a nurse, working for Plunket

Tony HickmottInterim Executive Director, 3DHB Corporate Services

∑ Wife employed by Capital & Coast District Health Board

∑ Sister-in-law is Medical Director for Student Health Services at Victoria University

Nigel FairleyGeneral Manager, Mental Health Addictions & Intellectual Disability Service, 3 DHB

∑ Fellow, NZ College of Clinical Psychologists

∑ President, Australian and NZ Association of Psychiatry, Psychology and Law

∑ Trustee, Porirua Hospital Museum

Shayne HunterInterim Chief Information Officer, 3 DHB

∑

Cheryl GoodyerCapability Manager, Māori Health Development Group

∑ Director, Otarere Māori Arts and Crafts

∑ Director, C A Goodyer Ltd

∑ Member, Goodyer family/whanau trust

∑ Various family members working across the DHB health sector –HV/Auckland/Canterbury DHBs

Taima FagaloaDirector, Pacific Health

∑ Cousin works as a community health worker for Ora Toa Health

∑ Director, TCF Consulting Limited

Dr Geoff RobinsonChief Medical Officer

∑ Chair, Medical Research Institute of NZ

∑ Trustee, Wellington Hospital & Health Foundation

Catherine EppsDirector of Allied Health, Technical & Scientific

∑ Nil

Andrea McCanceDirector, Nursing & Midwifery

∑ Trustee, Mary Potter Hospice

Dr Pauline BoylesSenior Disability Advisor

∑ Past President/ Advisor to Board, Wellington Riding for the Disabled

∑ Managing Director, Dream Achievers Ltd

∑ Member on the Ministry of Health National Advisory Group for Review of Behaviour Support Services


5

Jannel FisherCommunications Manager

∑ Nil


6

HOSPITAL ADVISORY COMMITTEE(s) PUBLIC

Wairarapa, Hutt Valley and Capital & Coast District Health Boards Page 1 NOVEMBER 2015

DRAFT MINUTES Held on Friday, 20 November 2015Boardroom, Capital & Coast DHBCommencing at 12:30pm

HOSPITAL ADVISORY COMMITTEE PUBLIC SECTION

PRESENT: Dr V Hope (Chair)Dr D Milne (Deputy Chair)Dr J Aitken Ms S KedgleyDr Leo BuchananMr John Terris (1.55pm)Dr Rob IrwinMr Ken LabanMs Katy AustinDr Bryan BettyDr Alan Shirley (Video Conference)

APOLOGIES Ms Fiona Samuel

IN ATTENDANCE: Dr Ashley Bloomfield (Chief Executive, Hutt Valley DHB)Ms Debbie Chin (Chief Executive, Capital & Coast DHB)Ms Adri Isbister (Chief Executive Officer, Wairarapa DHB)Ms Jill Stringer (Business Director, Wairarapa DHB)Ms Chris Lowry (Chief Operating Officer, Capital & Coast DHB)Mr Warrick Frater (Interim Chief Operating Officer, Hutt Valley DHB)Dr Geoffrey Robinson (Chief Medical Officer)Mr Nigel Fairley (General Manager, Mental Health, Addictions & Intellectual Disability 3 DHB)Ms Andrea McCance, (Director of Nursing & Midwifery, Capital & Coast DHB)Mr Russell Simpson, (Executive Director, Allied Health Technical & Scientific, Hutt Valley DHB)Dr Margaret Wilsher (Crown Monitor)Ms A Nicholas (Minute Taker)

Item 2.3∑ Roseanne McElroy (Manager, Occupational Health & Safety Capital & Coast / Hutt Valley DHB’s)

Item 2.4∑ Dr Shawn Sturland (Executive Director (Clinical) Quality Improvement & Patient Safety)

Item 2.5∑ Ms Chris Kerr (Clinical Services Director, Compass Health)∑ Ms Chris Bennett (Operations Manager, Patient Administration Services, CCDHB)∑ Ms C Goodyer (Manager Capability, Māori Health Development Group)∑ Ms Taima Fagaloa (Director, Pacific Health)

Four members of the Public


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1.0 PROCEDURAL BUSINESS

1.1 APOLOGIESThe Committee(s) ACCEPTED the apologies as listed above.

1.2 INTERESTS1.2.1 INTEREST REGISTERNo amendment was declared by the committee.

MOVED Judith Aitken SECONDED Leo Buchanan CARRIED

1.2.2 CONFLICT OF INTERESTNo conflicts of interest were declared for any items listed on the agenda.

CONFIRMED that it was not aware of any other matters (including matters reported to, and decisions made, by the Committee(s) at this meeting) which require disclosure.

1.3 CONFIRMATION OF MEETING MINUTES 18 SEPTEMBER 2015

RESOLVED that the minutes of the Committee meeting(s) held on 18 September 2015 taken with the public present were confirmed as a true and correct record.

MOVED Judith Aitken SECONDED Leo Buchanan CARRIED

The Committee(s)

1.4 MATTERS ARISING

REQUESTED:

The Committee (s)

a. RECEIVED the matters arising

b. NOTED that all matters have either been addressed in these papers or are scheduled for a future meeting.


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2.1 OPERATIONAL MONTHLY SERVICE REPORTThe report was taken as read and the Committee(s) Chair invited the Chief Executives or Chief Operating Officers to provide a brief summary of the report and mitigations pertaining to red flag indicators within the balanced scorecard section of the report.

The Committee(s)

a. Note the quarterly statistical summary report from the Health Funds Association NZ

b. Note the Wellington Regional Hospital Emergency Department Survey and findings

c. Note the financial reporting for the three DHBs for the September reporting period

d. Note the current performance and areas of focus reported in the Balance scorecards for the 3DHBs

e. Note the current Did Not Attend results for the 3DHBs and presentation from the CCDHB team to follow

ACTION:1. Provide more detail or metrics for measuring the national average statistics for growth and

population demand and the affect this has on ED’s. (H88)2. Include a standing paragraph within the report explaining the financial tables and the difference

between reporting styles of each DHB. (H89)3. The COO – Hutt Valley DHB to provide a paper to the Hutt Valley DHB Board re ED target and

mitigations/action to bring about sustainable improvement. (H90)

2.2 MHAID SERVICE 3DHB REPORT

The report was taken as read and the Committee(s) Chair invited Nigel Fairley to provide a brief summary.The Committee(s)

a) Note the work underway to incorporate the Wairarapa teams into the CCDHB webPAS patient administration system

b) Note that the MHAID Service 3DHB Patient Safety Group has been commissionedc) Note that the MHAID 3DHB Risk Advisory Group has been commissionedd) Note the continuation or refinement of the balance score card reportinge) Note the commencement of integration of clinical practices across the two acute inpatient unitsf) Note the opening of the Community Acute Day Service in the Huttg) Note the introduction of the resource management tool TrendCare in Te Whare O Matairangi

The committee members acknowledged the enormous amount of work being undertaken by Nigel and the team and REQUESTED that the acknowledgment is ENDORSED.


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2.3 QUARTERLY 3DHB HEALTH & SAFETY SERVICE REPORTS

In Attendance: Roseanne McElroy, Manager, Occupational Health & Safety Capital & Coast & Hutt Valley DHB’s (joined the meeting at 1pm)

The papers were taken as read and the Committee(s) Chair invited Roseanne McElroy to provide a brief summary on the Capital Coast and Hutt Valley DHBs’ reports.

The Committee(s)

h) Note the Wairarapa DHB’s new health and safety initiatives and improvementsi) Note the further strengthening of health and safety systems planned at Wairarapa DHB over the

next 12 monthsj) Note the new online line learning tool available to staff on how to stay safe around dogsk) Note that there were no serious harm incidents to report this quarter for Hutt Valley DHBl) Note Management are currently working through contracts with other providers including NGOs,

Aged residential care and contractors to ensure that Health and safety regulations are met and responsibilities for compliance specified

The Committee(s)Judith Aitken thanked management for the full and detailed reports and noted the very encouraging progress of the transition from past years to today.

ACTION:1. Wairarapa DHB to provide statistics of dog bites presenting to ED and note how these are dealt

with i.e. are local authorities / police advised. (H91)

2.4 QUARTERLY - 3DHB QUALITY REPORT

The reports were taken as read and the Committee(s):

m) Note the Health and Disability Commission six monthly report (January to June 2015), Wairarapa, Hutt Valley and Capital and Coast DHBs.

n) Note the CCHDB clinical measures report.o) Note that National Maternity Monitoring Group letter to the CEO’s dated 16 October 2015,

Wairarapa, Hutt Valley and Capital and Coast DHBs.p) Note the Infection Prevention and Control quarterly report, Wairarapa and Hutt Valley DHB.

The Committee(s)

ACTION:1. Capital & Coast DHB to provide an Infection Prevention and Control quarterly report with the next

quarterly Quality & Safety report including the incidence of antibiotic resistance and how this is being managed. (H92)


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2.5 CCDHB DID NOT ATTEND RATES (DNA) presented at 2.10pm

Presenters: Ms Chris Kerr (Clinical Services Director, Compass Health)Ms Chris Bennett (Operations Manager, Patient Administration Services, CCDHB)Ms Cheryl Goodyer (Manager Capability, Māori Health Development Group)Ms Taima Fagaloa (Director, Pacific Health)

Chris Lowry introduced the presenters and led the Committee(s) through the power point presentation.During the subsequent presentations and verbal updates the following was noted:

q) Note the establishment of a Did Not Attend (DNA) Oversight Group with DHB and Primary Care representatives.

r) Note the initiatives taken to improve Maori and Pacific non-attendance.s) Note the Pacific findings for non-attendance.t) Note the identified top 10 medical practices that have high Maori and Pacific Island non-

attendance rates.u) Note the work with Primary Health Organisation’s and Navigation Teams to improve non-

attendance rates.

ACTION:1. The committee requested the Hutt Valley DHB DNA Group prepare an overview presentation for

the next HAC meeting. (H93)

The Chair warmly thanked all the presenters and commended them for their interesting and informative presentation and updates and the subsequent thoughtful discussions they had generated.

The committee members acknowledged the wonderful job the CCDHB DNA Oversight Group are doing and REQUESTED that the acknowledgment is ENDORSED

The presentation was NOTED


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3.0 OTHER

3.1 GENERALNo items of general discussion were required.

3.2 RESOLUTION TO EXCLUDE PUBLICRESOLVED: The Committee(s) AGREED that as provided by Clause 32(a), of Schedule 3 of the New Zealand Public Health and Disability Act 2000, the public are excluded from the meeting for the following reasons:

Agenda Item NZ Public Health & Disability Act

Confirmation of Minutes of the previous “Public Excluded Section” of the Hospital Advisory Committee Meeting

Section 9(2)(i) of the OIA which enables the withholding of information to allow the carrying out, without prejudice or disadvantage, negotiations

Section 9 (2) (j) which enables the withholding of information to allow the carrying on, without prejudice or disadvantage, commercial activities.

Monthly Performance Report

Section 9(2) (c) enables the withholding of information to avoid prejudice to measures protecting the health or safety of members of the public.

MOVED R Irwin SECONDED J Terris CARRIED

The public section of the meeting adjourned at 3:05pm


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PUBLIC

Capital & Coast District Health Board NOVEMBER 2015 Page 1

SCHEDULE OF ACTION POINTS FOR HAC PUBLICMeeting date Ref Topic Action Arising Responsible How Dealt with Delivery

dateDate Completed

20 Nov 2015 H88 Operational Monthly Service Report

The committee requested that management provide more detail or metrics for measuring the national average statistics for growth and population demand and the affect this has on Emergency Departments

Chief Operating Officer

Include in board report

Feb 2016

H92 The committee requested that management provide evidence on how the DHBs ensure through their contracts with non-government organisations, Aged Care and contractors that Health and Safety regulations are met and directors and officers responsibilities for compliance mitigated.

Director, SIDU Include in board report

Apr 2016

H94 The committee requested management to provide the national statistics of what the incidence of antibiotic resistance is and how it is being managed.

Chief Operating Officer

Included in quarterly health and safety report

Feb 2016


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HOSPITAL ADVISORY COMMITTEE PUBLIC

Capital & Coast District Health Board Page 1 FEBRUARY 2016 Version 10.02.16

HAC DISCUSSION PAPER

Date: 12 February 2016

Author Chris Lowry – Chief Operating Officer, Capital & Coast DHB

Endorsed By Debbie Chin – Chief Executive Capital & Coast DHB

Subject Operational Monthly Service Report

RECOMMENDATION

It is recommended that the Committee:

a. Note the excerpt from the Health Needs Assessment relating to ED and acute inpatient demand

b. Note the progress being made with the planning to support the collocation of acute medical beds and provide flexi beds to better meet capacity requirements at times of high demand.

c. Note the work being completed to support the transfer of Ophthalmology volumes to Hutt Valley DHB

d. Note the current performance and areas of focus reported in the Balance scorecard

e. Note the quarterly Health & Safety Report

f. Note the quarterly Quality and Safety Report.

APPENDICES

2.1.1 Excerpt from the Health Needs Assessment

2.1.2 Mock-up of New Ward (6 East) Build Project

2.1.3 CCDHB Monthly Balanced Scorecard

PART ONE – KEY STRATEGIC ISSUES / PRIORITIES

1.1 Acute Demand Management – Growth and Population Demand

A Health Needs Assessment for the Wairarapa, Hutt Valley and Capital & Coast District Health Boards was completed in 2015 and provides a valuable perspective of what is happening in respect to the health needs of our populations, and the areas of priority focus for each DHB over the coming years.

An analysis of Emergency Department (ED) attendances and acute hospital inpatients was completed as part of the needs assessment. An excerpt from the report is attached – Appendix 2.1.1.

The report confirms the growth in ED attendances that has been experienced at CCDHB is 21% but notes that this is lower than the national average. The analysis of the acute admissions also shows a corresponding increase in acute admissions at CCDHB with the rates being highest amongst adults aged over 65 years.

PUBLIC Hospital Advisory Committee 12 February 2016 - DISCUSSION PAPERS

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Further work relating to population growth and demand is being completed as part of the Health Service Planning that is being undertaken across the three DHBs. This will inform future planning, service developments and investments for the DHB.

1.2 Collocation of Acute Medical Patients In December the Capital & Coast District Health Board (CCDHB) approved the business case to build a

new general medicine ward (to be named 6 East), in the Wellington Regional Hospital (WRH). This will

allow the collocation of acute medical patients into another dedicated ward for General Medicine and

also support the ability to flex resourced beds to better meet capacity requirements at times of high

demand. The plan is to have the ward ready for patients by July 2016 to ensure there are enough

inpatient beds at Wellington Regional Hospital (WRH) in winter 2016.

The first stage of the project was to relocate the renal service offices, inpatient gym and assessment

kitchen which are located in the proposed ward space. This phase is going to plan.

The chapel has been prepared for occupation and renal services moved in on 26 January 2016

The gym space will be completed by 8 February 2016

The kitchen will be completed by 26 February 2016

Storage space by 5 February 2016.

The design phase has progressed well. Concept designs for a new ward were developed in December

and the preferred design was agreed. A mock-up of the ward was built to seek staff opinion on the

design and was available for viewing and to provide discussion between mid-December and mid-

January. The feedback received from staff and unions is now being considered to develop the design

further to prepare for construction. The feedback that has been received from staff has been invaluable

and supports the design process to produce a well-functioning environment.

The planning for the construction phase is also on target.

The model of care and staff plan is being developed and it is hoped that recruitment will commence in

February using a phased approach to recruitment and appointment, allowing for full recruitment by

winter without creating a shortfall in other wards in our peak winter period – Appendix 2.1.2.

1.3 Ophthalmology Services

Work continues with Hutt Valley DHB (HVDHB) to utilise ten theatre sessions per month for Hutt domiciled patients requiring Ophthalmology surgery. Two surgeons will commence operating in February with the first list taking place on the 26 February 2016. The third surgeon will be scheduled to commence surgery once the equipment required to enable cataract surgery to be provided has arrived and been tested. Training of all relevant staff is underway.

1.4 Laundry Services

The transition of CCDHB laundry services to Allied Laundry Services (ALS) on 1 March remains on track.

The contracts will be signed off by the respective Shareholders, ALS Board and CCDHB CEO prior to 1

March 2016. The remaining CCDHB Laundry staffs that are not transitioning to ALS will have their

current roles disestablished on 29 February 2016.

The DHBS are committed to meeting their obligations under the respective agreements and are

working closely with the unions to agree the approach to managing redundancies, supporting staff and

identifying other employment opportunities both internal and external to the DHBs


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PART TWO – FINANCIAL PERFORMANCE

2.1 Capital and Coast DHB Hospital Operating Costs

The financial performance for December 2015 YTD was ($5,034k) unfavourable to budget. This variance

reflects the high hospital activity during the first half of the financial year.

The key variances to budget were:

• Revenue $2.185k favourable due to ACC and MOH contracts;

• Personnel ($254k) unfavourable - nursing costs are higher due to the higher level of activity. The

variance for the month of December was (719k) for nursing which also includes the impact of the

implementation of the nurses wage settlement and back pay;

• Treatment related costs ($4,962) unfavourable due to high hospital activity impacting on clinical supplies.

• Outsourced clinical services are ($246k) adverse due to the need to outsource for MRI and electives. Outsourced elective surgery is 486k favourable to budget December YTD. Actual expenditure for December YTD is $3,308k compared to$5,029k for the same period last year. This reflects the initiative to increase the throughput of elective surgery completed in house and the Kenepuru Orthopaedic initiative thereby reducing the level of outsourcing.

• Non-treatment related expenses ($1,204k) unfavourable.


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The following table summarises the HHS financial result.

Capital & Coast DHB

Provider (HHS)Operating Results

Actual Budget Last year

Actual vs

Budget

Actual vs

Last year

YTD Dec-15


Actual

vs

Budget

Actual vs

Last year

Annual

Budget

2,486 2,374 2,917 113 (431) Govt & Crown Sourced 16,680 15,764 20,407 916 (3,727) 29,995

1,064 972 1,187 92 (123) Non Govt Sourced 7,335 6,066 6,167 1,270 1,169 12,697

40,346 40,346 38,768 0 1,578 Internal Revenue 250,760 250,760 239,845 0 10,915 493,447

43,896 43,691 42,871 205 1,024 Total Revenue 274,775 272,590 266,419 2,185 8,356 536,139

Personnel

10,124 9,679 9,940 (445) (184) Medical 62,300 61,054 59,059 (1,247) (3,242) 121,771

11,762 11,043 9,850 (719) (1,912) Nursing 62,630 62,070 58,306 (560) (4,323) 125,406

3,010 3,156 3,874 146 864 Allied Health 20,510 21,370 21,399 861 890 40,476

619 694 678 75 59 Support 3,998 3,978 3,846 (20) (152) 7,921

2,451 2,830 2,574 379 123 Management & Administration 15,729 16,441 15,458 712 (271) 32,073

27,966 27,403 26,915 (564) (1,051) Total Employee Cost 165,166 164,912 158,068 (254) (7,098) 327,647

Outsourced Personnel

291 195 188 (96) (103) Medical 1,626 1,133 1,364 (494) (262) 2,249

5 5 (2) (0) (8) Nursing 32 30 29 (2) (3) 60

34 24 19 (10) (15) Allied Health 402 148 137 (255) (266) 288

161 155 167 (6) 6 Support 939 951 1,003 12 63 1,851

49 58 22 8 (27) Management & Administration 298 346 351 49 53 690

540 437 393 (103) (147) Total Outsourced Personnel Cost 3,298 2,608 2,884 (689) (414) 5,138

2,284 1,948 1,844 (336) (440) Outsourced Clinical Services 7,378 7,131 7,775 (246) 397 18,436

3,557 3,155 4,249 (402) 693 treatment Disposables 20,980 19,849 25,122 (1,131) 4,141 38,847

541 413 785 (128) 244 Disgnostic Supplies 4,509 4,082 5,228 (427) 719 6,552

912 874 944 (38) 32 Instruments & Equipment 5,658 5,421 5,349 (237) (309) 10,667

328 326 385 (2) 57 Patient Appliances 2,166 1,917 2,104 (248) (62) 3,758

1,282 1,467 1,302 184 20 Implants & Prostheses 9,662 8,806 7,928 (856) (1,734) 17,478

1,905 1,588 1,698 (317) (207) Pharmaceuticals 10,886 10,012 10,252 (873) (633) 19,273

338 (9) 97 (348) (242) Other Clinical & Client Costs 2,073 885 1,646 (1,188) (428) 766

11,149 9,762 11,305 (1,387) 156 Total Treatment related Costs 63,312 58,104 65,403 (5,208) 2,091 115,777

2,744 2,571 3,911 (173) 1,167 Infrastructure 17,450 16,246 24,547 (1,204) 7,097 31,763

(158) (156) (132) 1 26 Recharging (903) (889) (737) 14 166 (1,842)

60 60 60 (0) 0 Outsourced Other 362 361 362 (0) 0 723

2,659 2,668 2,843 9 184 Interest Depreciation & Capital Charge 16,135 16,257 17,124 122 988 32,116

5,306 5,143 6,683 (163) 1,377 Total Other Expenditure 33,044 31,976 41,295 (1,068) 8,251 62,761

44,961 42,744 45,296 (2,217) 334 Total Expenditure 264,820 257,601 267,650 (7,220) 2,830 511,322

(1,066) 947 (2,424) (2,012) 1,358 Net result 9,955 14,990 (1,230) (5,034) 11,186 24,817

Month -Dec-15 Year to Date Annual

Variance Variance

*Note – This report is for the HHS directorates and excludes corporate Directorates and Mental Health.


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Activity

A summary of total provider activity is shown in the table below.

Capital & Coast DHB

Hospital Throughput


Actual vs

Budget

Actual vs

Last year

YTD December 2015


Actual vs

Budget

Actual vs

Last year

Annual

Budget Last year

Discharges

1,779 1,709 70 Surgical 10,794 10,712 82 21,105

2,520 2,505 15 Medical 15,755 15,557 198 29,977

1,047 887 160 Other 6,182 5,929 253 11,693

5,346 5,101 245 Total 32,731 32,198 533 62,775

CWD

2,889 2,801 2,948 88 (59) Surgical 17,260 17,352 17,148 (92) 112 34,422 33,332

1,908 2,001 2,018 (93) (110) Medical 12,423 12,199 12,191 224 232 23,618 23,511

963 784 807 179 156 Other 5,476 5,212 5,208 264 268 10,135 10,085

5,760 5,586 5,773 174 (13) Total 35,159 34,763 34,547 396 612 68,176 66,928

Other

5,053 4,827 226 ED Presentations 31,301 30,437 864 60,249

3,320 3,082 238 ED Non-Admitted 20,481 19,256 1,225 38,862

1,733 1,745 (12) ED Admissions 10,820 11,181 (361) 21,387

1,415 1,219 196 Theatre Throughput 8,673 8,029 644 15,988

12,820 12,809 11 Bed Days on discharge 77,603 77,641 (38) 149,348

3.96 3.98 (0.0) ALOS Inpatient 3.89 3.82 0.1 3.90

2.45 2.60 (0.2) ALOS Including Day Patients 2.38 2.50 (0.1) 2.40

Month Year to Date

Variance Variance

Annual

Of note for the month of December 2015 • 245 more (4.8% higher) patient discharges than December 2014 • 13 less CWDs (0.2% lower) than December 2014, YTD 611 higher CWDs than YTD 14/15 • Length of stay is 0.5% lower than this period last year (3.96 December 2015 – 3.98 December 2014) The in-patient case weight volumes for December was 174 CWD higher than budget due to high IDF and

Local Acute volumes predominantly in the Surgery, Women and Children’s (SWC) directorate for

Neonates, Maternity and Surgical.

The graph below shows the combined impact of the inpatient average length of stay (ALOS) for the general specialties.

0.0

1.0

2.0

3.0

4.0

5.0

Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Cum

Inpatient ALOS

2014-15 InPatient ALOS 2015-16 InPatient ALOS

For the 2015/16 December YTP period, 35,159 CWD were delivered compared to 34,312 CWD for the

same period in 2014/15. The table shows where case weight volume variances have occurred versus our

budget as per the contract monitoring report.


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CWD Volume Analysis 2015/16 Including ED CWD (WEIS 15)

CWD Type

December

YTD Actual

December

YTD Budget

Variance to

Budget

14/15

December

YTD WIES 15

14/15 to

15/16 YTD

variance Area of Variance to budget

Local Acute 17,119.42 16,688.93 430 16,672 448 Haematology, Emergency, Neonatanl and Paediatric Medical Up General Surgery and General Medicine Down

Local Elective 5,803.49 6,128.76 (325) 5,809 (5) Cardiology Up Orthopaedics and Cardiothoracic down

IDF Acute 7,635.89 7,762.87 (127) 7,514 122 ENT and Neurology Up, Cardiothoracic, Haematology and Orthopaedics Down

IDF Elective 4,599.95 4,181.80 418 4,318 282 Cardiology, Neuro Surgery and Cardiothoracic Up

Total 35,159 34,762 396 34,312 847

PART THREE - BALANCED SCORECARD REPORTING

Good progress continues to be made against a number of the measures reported within the Balanced

Scorecard for the CCDHB. A summary of the areas that are of concern or are a high priority is outlined

below. (Appendix 2.1.2)

Shorter stays in ED

Occupancy in the hospital has reduced over the last two months with patient flow improving as a result. Compliance with the Shorter Stays in ED target in December and January was 90% and 94.4% respectively. The number of ED attendances remains higher than for the same period in the previous year. Weekly compliance is detailed in the graph below.

The admission rate has reduced when compared with the previous year and was 34% for the month of December (n= 1733) which is 12 fewer then December 2014.

JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC

2013 35% 35% 35% 34% 33% 34% 36% 38% 38% 37% 37% 37%

2014 38% 37% 37% 37% 37% 36% 38% 37% 37% 36% 37% 36%

2015 34% 35% 33% 33% 34% 36% 35% 34% 35% 35% 35% 34%


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Priority areas of improvement include:

SAPU are trialling pulling appropriate GP referrals directly from ED to SAPU for review

The management of acute Mental Health Patients presenting to ED

Duty Nurse Managers are facilitating the daily hospital status meeting 7 days a week, giving better oversight of the situation in the hospital.

Hospital at night meetings continues and provides an overview of patient’s likely needing admission and / or needing review by specialities.

Planning for the additional beds

Improved Access to Elective Surgery As of end of December the DHB is 218 discharges favourable to the health target as detailed below. Local Elective Discharges: Year to date results at December month-end The Local Elective YTD variance from planned discharge target for CCDHB is 79 below target for the period ending 31 December of which 17 relate to IDF outflow. The services driving the results are Ophthalmology 54, Cardiothoracic 31, Plastics and Burns 27 discharges behind. Arranged & Non-Surgical Discharges: We are 297 discharges ahead of target of target as at the end of December for arranged and non-surgical discharges, this is an increase on last month’s result of 270.

Electives Wait List The DHB is within the threshold for First Specialist Assessments and surgical treatment at the end of December

and January.

Better Help for Smokers to Quit The percentage of smokers provided advice remains slightly behind target with 94% achieved in December.

We are currently auditing in patient (IP) ward areas on a daily basis to ensure we achieve a high result in January.

Did Not Attend Rates Current performance The DHB is meeting the 6% target overall with a small improvement in Maori DNA rates which are 16 and 13% for the past two months. Pacific DNA rates are currently 16–17%.

DNA DNA DNA DNA DNA DNA DNA

Maori 14% 15% 12% 13% 14% 16% 13%

Pacific 15% 17% 13% 15% 18% 16% 17%

Other 4% 5% 5% 5% 5% 5% 5%

Total 6% 7% 6% 6% 6% 6% 6%

2015-DEC 2016-JANBy Ethnicity

2015-JUL 2015-AUG 2015-SEP 2015-OCT 2015-NOV

Allied Health

Consultant

Nursing

Technician

Total

9%

DNA

7%

4%

7%

6%

DNA

10%

7%

4%

6%

6%

DNA

9%

6%

4%

8%

6%

DNA

8%

7%

3%

7%

6%

DNA

9%

6%

3%

7%

6%6%

DNA

9%

7%

4%

8%

7%

2015-NOV 2015-DEC 2016-JAN

DNA

10%

6%

4%

7%

By Clinician

Type

2015-JUL 2015-AUG 2015-SEP 2015-OCT

DNA Project Update Work continues on initiaitves to further improve DNA rates.

Theatre Cancellations

The number of cancellations on the day of surgery in December was 82 - four less than November.

The Hospital/Service driven cancellations category showed an increase in the month of December with 25

cancellations for December (12 in November). Bed availability was the key issue for the month.

Numbers of elective cases cancelled on the day of surgery due to higher acutes also increased in the month with 18

patients cancelled. Per specialty, the greatest number cancelled for acutes was 10 for Orthopaedics, Neurosurgery

and Vascular each cancelled three for acutes, and Ophthalmology cancelled two.


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The Theatre/Service driven category decreased by five, to 25 cancellations (30 last month). The majority (19) of

these cases were cancelled due to insufficient time on the day, a decrease of four from the 23 cases cancelled for

this reason in November. Anaesthetic technician availability/illness also featured again this month, affecting

Paediatric and General Surgery, with 4 cases cancelled for this reason (three in November).

This remains a priority work stream within the theatre improvement project.

3.2 Elective Services Performance Indicators

NB ESPI 2 – First Specialist Assessment ESPI 5 – Surgical treatment

Preliminary results for December and January show we are within the threshold for both First Specialist Assessments (FSAs) and elective surgery.

3.3 Access to Diagnostics – Colonoscopies

Changes to reporting requirements from the Ministry of Health

The Ministry requirement for colonoscopy measures in the last financial year was on the accepted and received procedures for urgents (within 14 days), diagnostic (routine - within 42 days) and surveillance (within 84 days from the due date). From July 2015 the reporting requirements require the total number of accepted referrals waiting and procedures completed for the above categories. This recent change in reporting has therefore impacted on the monthly targets.

Categories Criteria Wait Time Performance Target Criteria

Procedures Completed Target

MoH Result

Urgent Within 14 days (75%) 100% Target Met 100% within 30 days 100% Target Met Target Met

Diagnostic Within 42 days (65%) 92% Target Met 100% within 120 days 100% Target Met Target Met

Surveillance Within 84 days (65%) 96% Target Met 100% within 120 days 100% Target Met Target Met

Targets for Urgent, Diagnostic and surveillance have all been met.

3.4 Access to Diagnostics – Radiology

(The radiology targets are based on referrals from the community and outpatients and does not reflect

the total demand on the service which will include the inpatient component)

CT – MOH target has increased the target from 90% to 95% in 2015/2016

MRI – MoH target has increased the target from 80% to 85% in 15/16.

Performance against the target for the year is detailed below: CCDHB MoH indicators (%)

Target July-14

Dec 14

Jan 15

Feb 15

Mar 15

Apr 15

May 15

June 15

July 15

Aug 15

Sep 15

Oct 15 Nov 15

Dec 15

CT 95 88 79 88 88 81 82 82 84 84 87 85 85 84

MRI 85 53 39 41 44 41 37 37 36 47 45 41 49 43

CT - MOH indicators: patients requiring a CT scanned within six weeks - 84% achieved for the month of


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December. The service is currently looking at options to increase capacity and the feasibility of extending the working day is being assessed as a future option. MRI – Patients requiring an MRI performed within six weeks – 43% achieved for the month of December. The recovery plan remains in place to ensure that we maximise what we are able to achieve internally. Outsourcing to Hutt Valley DHB and Pacific radiology continues. The number of patients waiting is slowly reducing but will not be cleared until the second MRI is installed. Planning for the second MRI is progressing well.

3.5 Faster Cancer Treatment

The target is that patients receive their first cancer treatment within 62 days of being referred with a high suspicion of cancer and the triaging clinician believes the patient needs to be seen within two weeks. The 62-day wait is measured from receipt of the referral to the date of the patient’s first cancer treatment (or other management). The target is that by July 2016, 85 per cent of patients meeting the criteria should commence treatment within 62 days, increasing to 90 per cent by June 2017. Approximately 25 per cent of newly-diagnosed cancer patients will be covered by the 62-day target. A large proportion of newly-diagnosed cancer patients will continue to access treatment through pathways not covered by the Ministry definition of the target.

Cancer Health Target

Year 2015 Month Less than 62 Days More than 62 Days Monthly Total Percentage <62 days

Q1 Jul 19 7 26 73%

Aug 25 5 30 83%

Sep 18 2 20 90%

Q2 Oct 18 10 28 64%

Nov 25 5 30 83%

Dec 17 0 17 100%

Grand Total 122 30 152 80%

Improvement since last month - 62day target National comparison table – CCDHB 4th nationally at 78.7% an improvement of 2.1% (national average 73%). Up to date data (as above) suggest that this may improve even more.

CCDHBs ‘indication of number of records submitted each month’ (62day target) (Calculated as

25% of expected cancer registrations) is 27 records per month and we are averaging 26 per

month (96%).

The Faster Cancer Treatment (FCT) work plan continues focusing on data capture via IT solutions and raising awareness of the FCT pathway. Areas of focus for improvement include lung and gynaecology tumours streams. We are commencing work with both gynaecology and cardiothoracic services to review referral and prioritisation processes post multi- disciplinary meetings (MDM).

31 Day Indicator - patients with a confirmed diagnosis of cancer to receive their first cancer treatment within 31 days

December 36 patients were included at time of reporting

29 patients (81%) were within the indicator timeframe


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We are currently not achieving our expected monthly cancer registration (107 per month) for the 31 day indicator. We are only submitting an average of 74 per month. It is hoped that with the ICT and raising awareness work that we are doing around high suspicion of cancer (HSOC) that this will improve.

3.6 Acute Coronary Syndrome – ANZACS-QI ANZACS-QI is a web-based system to support clinical quality improvement in secondary care. Key indicators are:

70% of high-risk patients will receive an angiogram within three days of admission. (‘Day of Admission’ being ‘Day 0’) CCDHB result for December was 87.5%. The regional result was 83.2%

The Central region has consistently met the target of 70% of high-risk patients receiving an angiogram within three days of admission; a target of 70% is realistic and clinically appropriate. It is important to review the results cautiously, for example each individual DHBs performance is measured as a percentage, however it is important to review the number of cases as well as often for smaller DHBs the denominator tends to be small, and therefore the percentile changes appear to be more significant. For example in December Wairarapa did not meet the target, of the three patients only two were treated within three days – 66.7%. Furthermore the reasons why the patient was not treated was clinically appropriate.


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PART FOUR – PROFESSIONAL LEADERS REPORTS

4.1 DIRECTOR OF NURSING & MIDWIFERY (DONM) UPDATE

Highlights

Nursing & Midwifery (N&M) Poster launched at December NETP Graduation - this summarises the key N&M priorities 2016-2019

Improving Patient Experience Safe effective, efficient care

NHS Thermometer trial HQSC CCDHB is participating in a HQSC trial of the NHS Patient Free Harm tool to inform discussion re adoption or not of this tool. This looks at the following areas: Pressure Injury prevention, Falls, Catheters & UTIs, venous thromboembolism and involves 10 weekly audits in CHS and an inpatient area.

HQSC National falls prevention evaluation CCDHB is one of three DHBs (Nelson, Tairāwhiti) to participate in the sector wide evaluation of the national Reducing Harm from Falls Programme to understand how well the programme, commenced in 2013/14, has been implemented and whether the outcomes are sustainable.


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Falls Prevention Programme The December Falls audits continue to show an improving trend for all five Care Interventions and a good culture of falls reportable events. The report indicates that Falls Prevention (FP) activities in inpatient areas are making a difference with fewer patients harmed from falls in 2014 and 2015 than in previous years. Pressure Injury Prevention (PI) Programme This new audit is supporting practice change for improved skin checks which are one of five key care interventions to reduce the pressure injury rate. CCDHB pressure injury work has been showcased in Ministry of Health HealthCERT publication and the Clinical Nurse Specialist (CNS) wound care presented in HealthCERT teaching for aged care providers.

Health Informatics (HI)

Regular meetings between the DONM Office and ICT are enabling progress on specific ICT projects. A plan to capture specific initiatives is underway

A joint HINZ, DONM Office and ICT forum for all staff in March will raise the awareness of staff in the use of data and update re ICT plan. Specific projects such as TrendCare, Health Care Home and Decision Support Unit (DSU) projects will be discussed. The International HINZ conference combines Global telehealth and Nurse Informatics NZ on 31 October - 3 November and will be attended by a DONM staff member

Care Capacity Demand Management (CCDM), TrendCare, Releasing Time to Care (RTC) The implementation of TrendCare has progressed with the focus now on data quality and redeployment of staff to match resources to acuity. Planning has progressed with the Independent expert to identify opportunities for improvements and further efficiencies. A project brief has now been completed to support the achievement of these improvements. A presentation of the project brief and deliverables will be made to the April HAC meeting.

Improving Patient Experience Compassionate care with dignity

Care Delivery Models

Model of Care work is in the planning phase for both 6East and to further the TrendCare/CCDM work above. Changes will include consideration of models of care for each pod – “we are a team”. This includes: mixed shifts and start times involving patients in planning the care via bedside handover knowing who's in the team and what they are doing - direction and delegation communication in the team roles in the team to coordinate care- Team Lead

Integrated Models to Improve Health Equity

The Health Care Home Governance Group work to improve care continuity between hospital and primary settings continues with DONM and DON Primary Health & Integrated Care (PH&IC) involvement. Engagement with community teams of nurse and allied staff who will be involved in the development of the Healthcare Home (HCH) model has begun.


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Workforce Leadership Knowing our workforce Sustainable workforce (Registered Nurse, Registered Midwife, Enrolled Nurse, Health Care Assistance) Monthly workforce data for annual leave, sick leave, overtime, Annual Practice Certificate (APC) compliance, Professional Development Recognition Programme (PDRP/QLP) compliance and performance appraisal compliance has been reviewed and is now being used by Associate Director of Nursing & Midwifery (ADONs/ADOM) and Operations Managers to progress compliance and improve the management of all leave types. Knowing the Primary Health Care sector nursing workforce is challenging due to the wide variety of settings, employers and types of nursing roles. Such data and understanding is currently not available. A work stream within the Nursing & Midwifery Leadership Team (NAML) team is being developed to establish the acquisition of a repeatable data set which will inform and enable appreciation of the workforce, where gaps and opportunity for future development exist to support hospital avoidance and reduce hospital length of stay. Sick Leave December sick leave data from the GL reflects a downward trend in nursing SL of less than 3%.

Strategic work with regional and national colleagues The DONM/DON PH&IC have: • Achieved a $25k joint CCDHB/HVDHB submission to improve waste management. This is driven by

CCDHB sustainability working group. • Attended the Wellington Regional Nursing Education Consortium of DHBs and Tertiary Education

Providers. • Attended the Sub-regional Information Management Service Level Alliance. • Attended and presented at the Pacific Nurses and Midwives Leadership fono. • Attended and chaired the Regional Immunisation Steering Group. • Submitted feedback of the proposed refreshed Massey University Bachelor of Nursing Programme. • Submitted proposal to Death Review Committee re nurses verifying Death (as per new legislation). • Attended the Palliative Care Conference in Wellington, sponsored by the Palliative Care Nurses, NZ • Central Region DONM representative on the CR Health Informatics Steering Group • CR DONM representative at the CR Quality and Patient Safety Alliance Group • DONM completed Level 1 ACP training • DONM Immunisation Executive Sponsor continues with 2016 influenza campaign commencing in

March. Immunisation vaccinator re- authorisation & training renewal due March 2016 • DONM input into TAS Regional Services Programme re Major Trauma Workstream Plan


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Engaging our workforce Staff are Engaged and Valued

Global Centre for Nursing Executives (GCNE) planning for 2016 within the CR will have a regional and national speaker on leadership hosted in Wellington

Peer Supervision training will start in February 2016

NETP graduation in December was a great celebration with over 200 attendees

Organisation of celebrations for the International day of the Midwife (5 May 2016) and International Nurses day (12 May 2016) have commenced. The theme is Nurses: A Force for Change: Improving health systems' resilience

The Directors of Nursing and the NAML team have a programme of visiting the Primary Health Care sector (i.e. ARC facilities) to engage and raise awareness of the professional development opportunities available through current DHB resources such as PDRP, NETP programmes, post graduate funding and other initiatives such as ACP education. During these visits, understanding is being sought as to the issues for professionals and the consumer when patients are transferred from the hospital services to the community setting in an attempt to understand what factors might support the most timely discharge of patients. Scholarship and Health Workforce New Zealand (HWNZ) Funding

A proposal to collocate all HWNZ contracts across CCDHB is being developed which should result in efficiencies regarding processes

The DONM Office are providing support/advice to nurses regarding postgraduate practicum, research and placement papers to support their HWNZ applications and service need

Enhanced Professionalism

The DONM with other professional lead colleagues is driving the Code of Conduct awareness launch. This is reflected in the Communication and Conflict Resolution course

NETP scholarships have been jointly agreed with Whitireia with 19 scholarships (partial or full) awarded (from 27 applicants) for Bachelor of Nursing, Bachelor of Nursing Maori (BN/BNM) and Social Work students across the three years

Growing our workforce Graduate Employment Maximised (NETP, NESP, Midwifery 1st Year of Practice (MFYOP)) CCDHB has recruited 18 NESP graduates (three Maori and three Pacific) to address projected recruitment needs particularly in Maori Mental Health, Adult Community teams, Intellectual Disability (ID) Services and the new national youth forensic inpatient unit (Nga Taiohi). 55 NETP graduates started in January intake (47 HHS and eight in Primary/Aged Residential Care (ARC)) with eight Maori and seven Pacific graduates and five Midwifery First Year of Practice. A review of the preceptorship programme is underway.

Develop Maori and Pacific Workforce • A proposed Central Region Maori and Pacific Nurses and Midwives Leaders Forum is being led by

CCDHB in April with guest speakers – Prof Mason Durie and Peseta Sam Lotu-iiga (Minister of

Pacific Peoples, Associate Minister of Health). This is a DONM priority is a Regional Services Plan

initiative.

• The Tu Pounamu Committee identified an issue with ethnicity demographic data collection within

Kiosk. HR aligned the recruitment information collected for new recruits with the health and

Disability Sector Standards; however the current ethnicity data in Kiosk is not aligned with this. The

second part of this work involves alignment/correction of this and then a campaign to encourage

staff to update their data in Kiosk.


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• Q2 ethnicity data being collated regarding ethnicity of patients and ethnicity of nurses and

midwives. This data supports CNMs to recruit a skilled workforce more aligned with the population

we serve and help meet health targets and organisational objectives.

• Maori and Pacific NETP graduates attend monthly hui and fono (HHS, Primary/ARC) for both

cohorts (January and August) to support them culturally in their first year.

Nurse Practitioners (NP) Responsive to Population/Service • Nurse Practitioner Candidates in Palliative Care and Neonatal Intensive Care (NICU) have submitted

Portfolio to the Nursing Council of New Zealand (NCNZ) • Nurse Practitioner Candidate in Older Person Mental Health – Psychogeriatric. This role sits across

the CCDHB inpatient and community psychogeriatric service and will strengthen linkage across the 3D with some clinical and liaison work in the Wairarapa

• The new HWNZ funding for the Nurse Practitioner (NP) Training programme has two Primary Healthcare (PHC) participants from the CCDHB region. One from Ora Toa Health Services and Te Aro Health Centre

• Interviewing for Community Older Person NP position is imminent.

4.2 CCDHB ALLIED HEALTH, TECHNICAL & SCIENTIFIC (AHT&S) UPDATE Central Region Two papers have been presented and endorsed by the Regional Workforce Hub in February that the Central Region Directors Allied Health has led: 1. Health Workforce New Zealand Post Graduate Trainee Funding. In line with the expectations of Health Workforce New Zealand, the Allied Health, Scientific and Technical leaders have developed a process where the funding that is available could be used more efficiently and flexibly across the Central Region and across the professions who meet the criteria so that the funding can be invested to the professions and DHBs who are best able to provide the training. 2. Skills Sharing Framework By sharing specific skills between professions and with assistants, patients could be treated more efficiently- so that there is less “cars up the driveway” or “practitioners at the bedside.” A safe and consistent framework for skills sharing could enable more flexibility in the way we deliver services, and develop new models of care. The Central Region Allied Health Directors have begun the process of seeking funding for the purchase of such a framework; the Calderdale Framework, and accompanying project resource. Student Placements A review has commenced of student placements for the relevant Allied Health, Scientific and Technical professions, to ensure that we have fit for purpose arrangements and agreements with the various universities. Health Pathways A business case for a 0.2 FTE six month position to co-ordinate the Allied Health contribution to health pathways has been approved by the Health Pathways Governance Group. The role has been based on the approach taken by Canterbury DHB, and will be a whole of health system role that enables current and appropriate advice from Allied Health practitioners to be woven into the relevant health pathways. Allied Health Scientific and Technical 3 DHB Strategic Approach Over 1000 people have now attended presentations of our Strategic Approach, with the formal presentation stage concluding in December. Teams, professional groups and services are now incorporating the strategic priorities into business as usual planning for the years ahead. We are also


28



delighted that NHS England has shown an interest in using the work to inform an Allied Health Strategy for England. In February 2016, the 12 month Action Plan supporting the 10 year Strategic Goals will be reviewed and refreshed as part of the annual planning cycle for the 3DHB AHS&T leadership team.

4.3 CHIEF MEDICAL OFFICER UPDATE

Sub-regional Clinical Groups 3D Clinical Governance Board This has now been set up to assist current and future 3DHB Clinical Services e.g. MHAID, Radiology to provide a forum, strategy and frameworks for their Clinical Governance. Recently Regional Public Health has reported on their Clinical Governance which appears strong regarding quality improvement and risk assessment. This process allows better visibility of activity to DHBs aside the Hutt Valley to whom Regional Public Health reports. MHAID are working towards aligning various guidelines and policies over the three DHBs and are developing their own specific 3DHB Clinical Governance framework which will report to the 3D Clinical Governance Board. The Clinical Governance Board will also be useful in assisting any interface Clinical Governance issues that may arise with the Wellington Southern Community Laboratory (WSCL) and Hospitals. Sub-regional Clinical Strategic Group The former sub-regional group has been reorganised as its mandate was becoming too complex (clinical IT, primary care integration aspects, Vision 2016-30, Health pathways, as well as hospital service integration). The new Group consists of Senior Clinicians with a prime focus on Hospital Service Integration and clinical leadership with advisory reporting to the three CEOs Laboratory I have continued to chair the Laboratory Clinical Reference Group which has considered clinical matters arising from the transition e.g. clinical reportable events and turnaround times. This has been ably supported by Russell Cooke the Laboratory Contract manager of Service Integration Development Unit (SIDU). Pleasingly the clinical issues are now minimal and this group has been disestablished. The first meeting of the Laboratory Alliance Leadership Team is scheduled for 24 February 2016. Hospital Clinicians have benefitted from the access to the regional Laboratory repository (icon). However GPs need to sign up to this system to have access to this benefit and WSCL has agreed to a proactive roll out to them. Clinical Leadership The Medical leadership is stable, and capable at CCDHB with the six Clinical Directors and over 50 departmental designated clinical leaders (no vacancies). We encourage their participation in clinical leadership programmes such as the in-house Frontline Leadership modules, as well as training now being increasingly offered through the Health Quality and Safety Commission. However, coming up to 68 this year I have taken retirement from March and the CMO position has been advertised, as indeed have the CMO positions over Hutt Valley and Wairarapa (new).


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Clinical ICT Engagement Peter Hicks is the Senior Medical Officer with an ICT Clinical Advisory position. It is important to obtain wider clinical engagement into local, sub-regional and regional Clinical ICT. He is establishing a clinical IT advisory group to assist the IT/clinician interface. Medical College accreditation of training These reviews occur regularly from the Colleges and there are no important compliance issues to report at CCDHB. Clinical Innovation/Demand Management Group (Choosing Wisely) I chair this group which is a subcommittee of the Clinical Practice Committee (CPC). We are currently working on immunoglobulin and other expensive Blood Products (costs increasing), vascular surveillance imaging, other surveillance imaging in patient’s DHB of domicile, changes in routine intravenous fluids (following local published) research outcomes, and approaches to containing Pharmaceutical costs


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Capital & Coast District Health Board

HAC INFORMATION PAPER

Date: November / December 2015

Author Nigel Fairley, General Manager, MHAID Service 3DHB

Endorsed By Debbie Chin, CE, Capital & Coast DHB

Subject MHAID Service 3DHB Report for Hospital Advisory Committee (HAC)

RECOMMENDATION

It is recommended that the Committee NOTES the contents of the report

APPENDICES

2.2.1 MHAID Service 3DHB Balanced Score Card 2.2.2 Provisional Suspected Suicide deaths by DHB Region between July 2012 and June 2015

1.0 OVERVIEW

This has been another busy period for MHAID Service 3DHB. High occupancy in both acute units, Te Whare Ahuru and Te Whare o Matairangi, has contributed to increased average length of stay. For both units two newly appointed Senior Medical Officers (SMOs) started 1 February 2016. The construction works in the Intensive Care Unit (ICU) of Te Whare Ahuru to reconfigure clinical and client spaces has commenced and is scheduled to be completed in early March 2016. TrendCare (a patient acuity tool for nursing) implementation is underway at Te Whare O Matairangi and Complex Case reviews were introduced in September 2015 in Te Whare Ahuru, Te Whare o Matairangi and Rangatahi (the regional adolescent unit at Kenepuru). The first MHAID Service 3DHB mental health Nurse Practitioner (at Psychogeriatrics) was appointed and commenced in January 2016.

2.0 BALANCED SCORE CARD

The balanced score card for MHAID Service 3DHB is attached – Appendix 2.2.1. We have been finalising this and some of the challenges have included the different way in which the data is collected in the 3DHBs. The Score Card is colour coded so it is clear which of the factors are the National Benchmarking KPI programme, national health targets, Health Quality & Safety Commission KPIs, Mental Health & Addictions Services targeting Ministry of Health Performance measures, and our own targets. Data quality remains a priority for the Ministry of Health and will be a focus of the

MHAID Service analysts leading up to National Collections Annual Maintenance Project (NCAMP)

2016.

Seclusion stats for the Hutt are higher. A factor contributing to this is the environment of the unit. A project, led by Director of Nursing for MHAID, is looking at the data and identifying ways of reducing the number of incidents.


31



The Mental Health Act section 29 data (community treatment orders) has significantly improved given the work undertaken last year. The section 29 CCDHB data is real time so there are fluctuations in these figures as the legal status information is often updated retrospectively.

3.0 CRISIS RESOLUTION SERVICE

The decision document has been finalised, and circulated to staff and unions. The decision is to have one integrated Crisis Resolution Service across Hutt Valley DHB and CCDHB, with mental health crisis staff based in the Emergency Departments, the new Police hub, and the community. Following on from meetings last year with staff and unions, two meetings with CATT staff in CCDHB and Hutt Valley DHB were held in early February to involve staff in the specific implementation details of the new service. A number of working groups have been established including “A Day in the Life of a Crisis Resolution Team”, rostering, policies and procedures, and technology. The new integrated Crisis Resolution Service will be operational in March 2016.

4.0 WOMEN’S AREA IN RANGIPAPA

The women’s sub-unit in Rangipapa was opened mid December. This is a unique facility in New Zealand being the first women’s only dedicated area in forensic services.

5.0 NGA TAIOHI YOUTH FORENSIC UNIT Nga Taiohi is the new national youth forensic secure inpatient unit that is being built at Kenepuru

Hospital, co-located with the regional adolescent unit and the national youth intellectual disability facility. The Governance Group for Nga Taiohi continues to meet monthly, review and monitor progress. Recruitment is presently being undertaken, with interviews completed for some positions. A meeting was held with CYFS to formulate the MOU between the two services, and a meeting with the managers of the four CYFS’ residences is planned for this month. A critical role in the operation of the unit is that of resource co-ordinator who will “chair” the meetings with representatives from each of the forensic youth services regarding admissions and discharges. It is planned that these representatives will meet in Wellington in early March to visit the site and discuss the unit’s policies and procedures. The construction of this unit is on time, with the opening planned for 21 April 2016.

6.0 CONSUMER REVIEW A review has been undertaken looking at consumer involvement in MHAID Service 3DHB. The

reviewers are Helen Hamer, the consumer consultant from Waitemata MH Service, Sue McCullough (PSA), MHAID Service 3DHB Director of Allied Health and the Maori Advisor. The group will report by the end of February 2016 with an options paper. They have consulted widely and considered models in other DHBs and international literature. We will keep the Boards informed of the outcome of the review.

7.0 POLICE LIAISON

There has been significant work over the past year with Police. An Interagency Group is now in place, meeting approximately bimonthly. It includes the Police, MHAID Service and both Emergency Departments. This is chaired by the Clinical Leader for MHAID Intensive Services. There are a number of specific projects underway. A specific handover form to be used by Police when they bring people to EDs has been developed and agreed to. The 10 high users of emergency services have been


32



identified, and with individual consent, a care management plan for each individual will be prepared that will be used by all emergency services. A regional Governance Group is also being established. The DHBs will be represented on that by the Executive Director of Nursing for CCDHB, the Medical Director for MHAID Service 3DHB, and the General Manager for MHAID Service 3DHB. MHAID Service 3DHB is helping Police develop protocols, check lists and a set of questions for Police on the ground to use in relation to Section 109 of the Mental Health Act. Section 109 is the power of Police to pick up an individual in a public place who they believe is behaving in a mentally disordered manner.

8.0 INTELLECTUAL DISABILITY SERVICE UPDATE

Claims Audit: While this audit is not finalised there is agreement on the principal facts. The original suggestion that CCDHB had over-claimed have been withdrawn and an apology provided. There is now agreement that CCDHB is owed slightly over $13,000 and our finance team will be sending an invoice shortly. The final reply to the draft audit has been sent and we expect this audit to be closed following a meeting with the auditor as requested in our response. Assisting Ministry of Health: The Ministry of Health are reviewing some individual packages of care for people with a disability and have asked our National Intellectual Disability Care Agency (NIDCA) to assist. NIDCA is a national service provided by Capital & Coast DHB and is recognised for its expertise assessing care for people with a disability.

9.0 SERVICE REVIEW There are various reviews under way which, when put in place, will streamline some of the services presently operating. In conjunction with SIDU, an important review is looking at the alternatives to hospitalisation within the adult acute area. This review will be completed by the end of February 2016. Specific work is also being undertaken around the adult and youth models of care.

10.0 SUICIDE INFORMATION (as requested by the HAC Committee)

Attached to this report is a three year summary of suspected suicides in the region for 2013 to 2015 – Appendix 2.2.2


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Author Roseanne McElroy, Manager Occupational Health & Safety

Endorsed By Chris Lowry, Chief Operating Officer

Subject Health and Safety Quarterly Report

RECOMMENDATION

It is recommended that the Boards note the contents of the Quarterly Health and Safety report for the period October – December 2016.

OVERVIEW Processes related to DHB procurement and engagement of contractors has been reviewed from a staff health and safety perspective and alignment with new legislation. We are working with our contractors to embed this into practice. A new template has been developed to guide the health and safety assessment process and revised wording will be included in the new Procurement Policy. This is currently being consulted on before embedding into practice. Proposed Management of Health and Safety of Contractors Policy (aligning with new legislation) has been drafted and will go out for consultation in February. MANAGERS HEALTH AND SAFETY TRAINING A training package introducing the new health and safety legislation for managers has been developed. This includes a mixture of e-learning modules and face to face, hour long, lunch time case study workshops to be attended by all managers. E-learning training for managers will be included as part of the core competency programme and has been given priority by the Learning and Development team for completion by the end of February. Gap analysis of DHB systems to prevent and manage physical assaults on staff in the workplace Draft report with recommendations for improving systems has been completed. This report will be available for distribution when finalised and approved. INCIDENTS

No clear contributing factors, applicable across all services, account for any changes in incident trends noted across the most commonly reported hazard categories.

Assaults on staff by patients remain the most commonly reported event – the large majority of these occurring in mental health services. The number of assaults reported this quarter was less than in previous two quarters. The table showing the number of incidents per hazard category is included at end of this report.


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HEALTH & SAFETY RISKS The key health and safety risk is: 1. Ongoing high number of assaults on staff

The gap analysis of DHB systems to prevent and manage physical assaults on staff in the workplace has been completed. The report is currently being reviewed. This will inform actions required to further assist with managing this risk. An assessment of the current maintenance programme is being undertaken to assist with prioritisation and will inform the DHBs capital planning and master plan. HEALTH &SAFETY PRIORITIES FOR NEXT QUARTER 1. Implement a consistent organisation wide process for the on-going monitoring of Contractor

and lease holders health and safety practice. 2. Ensure completion of e-learning H&S training package for managers by February. Training is

required so managers are up to speed with changes affecting their responsibilities when new legislation comes into force 4 April 2016.

3. Support health and safety representatives to attend WorkSafe endorsed and funded training on new H&S legislation and how this impacts on their role in the workplace.

4. All workplaces to begin using online workplace hazard registers in February.

HEALTH &SAFETY FOCUS TOPICS Posters and information to stimulate H&S discussion and promote continuous improvement initiatives were distributed to all work areas via the H&S representative network on the following topics.

MONTH HEALTH & SAFETY TOPIC

KEY MESSAGE

October Safe Handling

Good handling and carrying techniques prevent injury (Childs Play DVD promotion)

November Slips ,Trips and Falls

Safety on Stairs

December New H&S legislation on the way Focus on assessing risks to health and safety in the workplace

And coming up….

January Continuation of December’s Topic

February Introducing online hazard registers

March To be advised


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CCDHB Assaults on Staff Events - Run Charts Graph 1

NUMBER OF INCIDENTS REPORTED AFFECTING STAFF PER DIRECTORATE/CORPORATE GROUP

OCTOBER TO DECEMBER 2015

Number of incidents last quarter (in brackets)

Incident type/hazard

category

Mental

Health

Services

Medical &

Community

Health

Surgery

Women &

Children

Clinical

Support

3DHB services

Total number of

incidents in hazard

category across

DHB

Blood & Body Fluid

Exposures

1 (2) 13 (11) 29 (23) 3 (8) 0 (0) 46

Assaults 92 (103)

8 (4) 3 (5) 1 (0) 0 (0) 104

Slips/trips/Falls 6 (7)

12 (5) 9 (10) 6 (7) 1 (1) 34

Manual handling

Patient

3 (1)

13 (13) 12 (10) 0 (1) 0 (0) 28

Manual Handling

Object

2 (1)

4 (6) 7 (6) 2 (5) 0 (1) 18

Running into or

being hit by object

4 (4) 6 (1) 6 (7) 0 (1) 1 (1) 17


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Graph 2

NB - Dataset source for all graphs: Staff events figures for physical assault are provided by Organisational Health and Safety Service as these are not recorded in the Reportable event database under category ‘EMPLOYEE GENERAL INCIDENT’.


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Capital & Coast District Health Board 1



Author Shawn Sturland – Executive Director Clinical Quality Improvement & Patient Safety Directorate CCDHB

Caroline Tilah – Executive Director Operations Quality Improvement & Patient Safety Directorate CCDHB

Endorsed By Chris Lowry - Chief Operating Officer, Capital & Coast DHB

Subject CCDHB Quarterly Quality Report for Hospital Advisory Committee (HAC)

RECOMMENDATION

It is recommended that the CCDHB Hospital Advisory Committee receive and note the report for Quarter 2 - October to December 2015.

1.0 INTRODUCTION

As a DHB we are working towards meeting government goals, the triple aim outcomes and the CCDHB priorties. Where able we have focussed on sub regional collaboration.

2.0 CONSUMER VALUE (PATIENT EXPERIENCE) Focussing on consumer value encourages our DHB to involve our communities in improving current performance and planning for the future, and to achieve improved health outcomes and equity for our populations. We receive consumer information through our complaints and compliments feedback, the National and CCDHB patient satisfaction surveys and through consumer engagement. This information is analysed and reflected in continuous improvements.

2.1 COMPLIMENTS & COMPLAINTS

The tables below show the number of compliments and complaints for CCDHB from October to December 2015.

CCDHB Oct Nov Dec Total

Number of Complaints by Month 71 70 46 187

Number of Compliments by Month 100 82 57 239

CCDHB - Complaint themes

Mar to May 15 Jun to Sept 15 Oct to Dec 15

Standard of Clinical Care 47% 37% 35%

Communication 19% 24% 25%

The number of complaints relating to standard of clinical care (All care/treatment received from medical, nursing, allied health) has decreased. This may be a result of the increased auditing against best practice that commenced in April following the centralisation of our care process audits, as well as the roll out of the revised Early Warning Score process in September that detects early deterioration and prompt treatment. There will be an increased focus in 2016 on improving patient communication. Initial data analysis of these complaints will be against the following six groupings to inform focussed improvements:

1) Rudeness or other negative communication by staff member 2) Wrong or incomplete information given 3) Poor standard of written information - letters/ brochures / information sheets


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4) Any information given by medical/ nursing/ allied health 5) Not told about change in appointment time 6) Way in which spoken to All complaint themes for the period October to December 2015 are demonstrated in the Pareto Chart below:

2.2 National Quarterly Patient Experience Survey The Health Quality & Safety Commission (HQSC) have been facilitating a quarterly National Adult Patient Experience Survey (Adult Inpatient’s over 15 years of age and excludes Mental Health & Te Mahoe) since August 2014. This is based on four domains: communication, partnership, coordination, and needs (physical & emotional). CCDHB’s results have shown improvement and are as follows:

HQSC National Adult Patient Experience Survey: Q2 (November Results)

Date Aug 2014 Nov 2014 Feb 2015 May 2015 Aug 2015 Nov 2015 Comments

Weighted Scores for Communication CCDHB and NZ

CCDHB 8.1 8.3 8.5 8.5 8.4 8.4 CCDHB same as National

score NZ 8.2 8.3 8.4 8.4 8.4 8.4

Weighted Scores for partnership CCDHB and NZ

CCDHB 8.3 8.4 8.5 8.5 8.4 8.5 CCDHB same as National

score NZ 8.3 8.5 8.4 8.4 8.6 8.5

Weighted Scores for Co-ordination CCDHB and NZ

CCDHB 8.2 8.2 8.3 8.4 8.4 8.4 CCDHB lower than national

score NZ 8.3 8.4 8.3 8.3 8.6 8.5

Weighted scores for Physical and Emotional Needs CCDHB and NZ

CCDHB 8.4 8.5 8.6 8.5 8.6 8.5 CCDHB lower than national

score NZ 8.4 8.6 8.5 8.4 8.8 8.7

Response Rate

CCDHB 33% 33% 33% 32% 38% 35% Significant higher

response rate (& 100% by

email)

NZ 27% 27% 27% 24% 23% 24%


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2.3 CCDHB Monthly Patient Experience Survey CCDHB also undertake a monthly Patient Experience Survey (commenced in November 2013) for 10 months of the year. (Refer Appendix 2.4.1). Coordination and communication between hospital, home and other services had consistently remained the second lowest score. Focussed improvement following data analysis in March 2015 determined five main improvement work streams:

Service coordination

Follow up care

Discharge information

Appointments

Discharge Medications The first work stream commenced in August 2015 on discharge medications, with CCDHB working in partnership with the Health Quality & Safety Commission (HQSC) focussing on a combined improvement project (as part of the Ko Awatea Improvement Advisor Programme) on improving patient’s knowledge on medication side effects on discharge. The focus ward is the Surgical Assessment & Planning Unit (SAPU).

2.4 CCDHB Engagement At CCDHB our Directorates have established their own mechanisms for engagement with the relevant service specific community consumer groups. Mental Health has progressed furthest with consumer participation and have fully embedded consumer views at all levels. A Regional Strategic Disability Advisory Group has been established, and a short term CCDHB Consumer Working Group that focuses on providing consumer feedback on primary and secondary initiatives (while we further develop and confirm the future direction of the council). The Consumer Working Group has so far reviewed and provided feedback on:

Revised outpatient appointment letters.

Quality Accounts 2014/15 layout.

Consumer Advisor handbook.

Providing a consumer voice to ICT regarding “Your Health Information” project.

Feedback on the MOH Health Strategy

Format of patient information pamphlets Our Director for Communications is currently collating a comprehensive stock take of consumer engagement activities.

2.5 CCDHB Quality Accounts Following direct consumer feedback on our 2013/14 accounts CCDHB, in partnership with the Consumer Working Group, has completed the 2014/15 Quality Accounts. These are to be published in all three local community newspapers at Waitangi Weekend and an A2 size be displayed in GP Practices as a poster, and can also folded down to an A4 size for waiting room stand display. The intent of the Quality Accounts is to provide our community with examples of how we have been improving services supporting their health needs during 2014/15. (Refer Appendix 2.4.2).

3.0 EFFECTIVENESS Effectiveness focuses on monitoring and evaluation of patient care and performance in relation to our peers to ensure focussed quality improvement.


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3.1 HQSC Open Campaign - (Quality Safety Markers) The Health Quality & Safety Commission is driving improvement in the safety and quality of New Zealand’s health care through the national patient safety campaign Open for better care. The quality and safety markers (QSMs) help evaluate the success of the campaign nationally and determine whether the desired changes in practice and reductions in harm and cost have occurred. CCDHB performance for 2015 is detailed in the following table (NB: October to December submission due 12 February 2016):

Marker Definition NZ Goal

NZ Avg

Jan – Mar15

Apr – Jun 15

Jul – Aug 15

Comment

FALLS: Percentage of patients aged 75 and over (Maori and Pacific Islanders 55 and over) that are given a falls risk assessment.

90% 93% 87% 92% 94% Above the Target

FALLS: Percentage of patients assessed as being at risk have an individualised care plan which addresses their falls risk.

90%

90% 91% 95% 99% Above the Target

SAFE SURGERY (previously perioperative harm): Percentage of operations where all three parts of the surgical checklist

90% 97% 98% 99% Above the Target – Marker discontinued by the HQSC as of July 2015

HAND HYGIENE: Percentage of opportunities for hand hygiene

80% 80% 72% 79% 81% Above the Target

SURGICAL SITE INFECTIONS: Antibiotic given (0-60 minutes before “knife to skin” (baseline date January to March 2014)

100% 96% 98% 100% 100% Met the target

SURGICAL SITE INFECTIONS: Right antibiotic in the right dose - 2 grams or more cefazolin given

95% 95% 98% 98% 98% Above the Target

SURGICAL SITE INFECTIONS: Appropriate skin antisepsis in surgery using alcohol/ chlorhex or alcohol/ providone iodine

100% 99% 100% 100% 100% Target met

3.2 Certification CCCHB had their certification surveillance audit the week of 13 April 2015 (certified for three years). The surveillance audit assessed CCDHB against sixteen of the Health & Disability standards, and the corrective actions from our certification audit from September 2013. Of the 18 actions from the September 2013 audit nine were closed, and there were six new actions. On 16 September we fedback to the Ministry of Health (MOH) progress with high priority (one month) action for criterion 1.3.6.1 requiring CCDHB to develop and implement a short and long term strategy to meet the resource needs for the provision of high dependency care at Wellington Hospital. On 30 November 2015, CCDHB fed back to the MOH the medium priority actions (three months). (Refer Appendix 2.4.3) Annual practicing Certificates (APC’s)–98% APC’s reported being current which is a signifcant improvement from the reported 60% in April 2015.

Credentialing – As of 30 October 2015 it was reported that 38% (159/430) Senior Medical Officer’s (SMO’s) have been credentialed in the last 12 months. Issues relating to data collection and reporting are impacting on reported results and are being worked through. This is a priority for the Chief Medical Officer (CMO) who is working towards 100% reported compliance by March 2016.


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http://www.open.hqsc.govt.nz/

http://www.open.hqsc.govt.nz/

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Play Therapists –Play Specialist Leader at Counties Manukau is to do a site visit before the end of the year and advise CCDHB on developement of the play specialist role and servcie provision.

Improvement through introduction of care process auditing focussed on best practice, centralsation of the audit result leading to improved visibility through reporting and actions taken to support improved practice:

Patient goals - CCDHB overall compliance has increased from 16% in November

2014 to 50% in October 2015 Risk assessments CCDHB overall compliance from November 2014 to latest

audit: Delirium Risk Assessment 64% to 85% (October 2015)

Cognitive Risk Assessment 70% to 79% (October 2015)

Family Violence Screening 50% to 51% (August 2015)

Infection Prvention & Control 80% to 85% (September 2015)

Falls risk assessment 71% to 95% (October 2015)

Pressure Injury Risk Assessment 25% to 47% (November 2015)

CCDHB launched the revised early warning score (EWS) pathway and vital sign charts hospital wide in September 2015. All areas were updated regarding the importance of good documentation and the escalation pathway.

3.3 Controlled Documents (Policies/Procedures/Protocols/Guidelines) As a DHB we are actively engaging in policy development and the development of sub regional documents. Key achievements from October to December 2015 are as follows:

Launch of the 3DHB Code of conduct, 3DHB Disciplinary and 3DHB Harassment prevention and 3DHB Managing and Preventing workplace bullying, harassment, discrimination and victimisation documents

Medical records (electronic and hard copy) content and documentation policy was updated to clarify the process for staff

The blood component and product transfusion was issued after a major review to include newly available blood products

Coroner policy revised and issued

The use of interpreting services policy updated to clarify the process for staff

3.4 Clinical & Quality Safety Measures At CCDHB we produce a monthly clinical measures report that contains control charts for an agreed 13 clinical and quality measures (data from our reportable events and other relevant data sources), - Appendix 2.4.4. As at 31 December 2015 12 of the 13 measures all showed normal variability. The “CCDHB Reported Incidents of Restraints/Supportive Devices” showed variation outside the normal control limits (special cause) that required us to look more closely at the data. We have established that the increase in reportable events was for 3 areas within Mental Health Services– Te Aruhe, Te Whare Ra Uta and Haumietiketike. These were mainly related to a few patients that required restraint due to their cognitive condition. All restraint events are required to be recorded and are reviewed at the monthly Seclusion & Restraint Minimisation Group.

3.5 Infection Prevention and Control (IPC) IPC Surveillance activity is carried out in accordance with specified objectives priorities and methods as specified in the Surveillance policy


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CCDHB is one of three DHBs which achieved all three Health Quality & Safety Commission markers for preventing surgical infection in orthopaedics (the only tertiary hospital to do so). The current Surgical Site Infection rate is 1.7% (compared to national average of 1.2%). Our higher rate may not be statistically significant, but also reflects our tertiary status with a high rate of revision surgery. In addition, the indicator includes superficial infections which have increased lately but are of questionable significance.

4 RISK (SAFETY) CCDHB is committed to providing a safe environment for all patients/clients who use our services and recognise that despite the best intentions of the staff, incidents and errors will occur. CCDHB is committed to ensuring that the risk management and patient safety systems enable early identification, review and system changes to improve safety.

4.1 Risk Framework CCDHB is updating the Risk Management Policy in conjunction with Occupational Health and Safety to ensure that the changes to the Health and Safety Legislation which take effect later this year are reflected. The DHBs in the sub region are currently engaged in the review of the existing CCDHB Reportable Event System to enable a 3DHB upgrade of the existing electronic reportable events and complaints/compliments system across the three DHBs. The system is called SQUARE (Safety, QUality & Reportable Events) and is planned for go live in late March/early April 2016.

5 WORKFORCE (INCLUDES SUB-REGIONAL COLLABORATION) Workforce is focused on how we are facilitating regional and sub-regional collaboration and thereby ensuring we are getting the best value for public health system resources.

5.1 Clinical Governance Structure A 3DHB Clinical Governance Board has been established to ensure clinical governance of the 3DHB clinical services, such as the integrated mental health, addictions and intellectual disability services (3DHB MHAID).

5.2 Highlights

As part of the National Opioid Campaign CCDHB’s aim is to reduce constipation (harm) associated with opioid use on Ward 6North (Elective Orthopaedic Surgical patients) by 25% by June 2016. Representatives from CCDHB and HVDHB/WDHB attended a Learning Session (L3) in Auckland on 10-11 November 2015. CCDHB is part of the HQSC safety thermometer pilot and three staff attended the National Safety Thermometer (NST) workshop held on the 30 November 2015. It is a tool to track harms associated with falls, pressure injuries, venous thrombosis embolism and urinary tract infection associated with catheter use. CCDHB focussed on use in the community setting in the absence of another data capture tool. Patient Safety Week was held 2-5 November 2015. The theme was “Communicating Well”. Communicating well with patient’s means going back to basics, such as introducing yourself, using plain English rather than jargon, and most importantly giving patients the chance to ask questions and say what matters to them. All staff who have patient contact were encouraged to wear ‘Hello, my name is’ name stickers on Monday, 2 November 2015. The stickers are available in English, Maori and Samoan and were distributed to the work place the week prior. Terminally ill UK doctor Kate Granger began the ‘Hello, my name is’ campaign when she noticed that many of the medical staff treating her did not introduce


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themselves. Introducing yourself to a patient is about much more than just exchanging names. It is about making a human connection and building trust. It sets the foundation for better communication about every aspect of a patient’s care. The name stickers are a great reminder to staff of the importance of good communication, as well as showing patients their questions are welcomed. Patient safety week had five specific themes.

Monday Hello my name is/ ISBAR

Tuesday Health Literacy – Language that we use

Wednesday What matters to you – Focus on discharge and being safe

Thursday Let’s talk about the future –Advanced Care Planning

Friday Celebrating the care team “All Staff”

Each inpatient ward had a pack of HQSC resources to display and give to patients and staff,

as well as the support services that have direct patient contact. There were daily displays

in the atrium at Wellington Hospital and at Kenepuru Hospital, and key staff were available

from12-1pm to talk to the public. The Grand Round on Thursday was focussed on

communication, and there were three staff competitions. Ward 6North won the modelling

good communication behaviour competition - photo below. (Refer Appendix 2.4.5).

Violence Intervention Programme (VIP) White Ribbon Day was celebrated on 25 November 2015. Resources including posters, balloons, banners and ribbons have been purchased and are available to service areas for display. Wellington Regional Hospital’s Emergency Department (ED) now has 24/7 support for victims of domestic violence thanks to a new partnership with Wellington Women’s Refuge. In ED all women over the age of 16 are screened for domestic violence and given the option of talking to a support person. During the day this would be a social worker from the hospital who would give them a safety assessment and offer on-going assistance, now Wellington Women’s Refuge has stepped in to provide an after hour’s service. “We had been involved with the group who were working on domestic violence screening for some time, and were happy to help,” says Wellington Women’s Refuge manager Philippa McAtee. “Within one hour we can get one of our trained volunteers down to the Emergency Department (ED) to provide support to these women – whether it’s just to have a chat, to be put in touch with one of our community social workers, or they need to go to our safe house.” Clinical nurse specialist Jennifer Irving says the response from ED staff performing the screenings has been positive. “We screen for a number of health issues, providing referrals for people who come in as smokers or frail elderly, and we have been thoughtful introducing the screening into ED to ensure there is support for people, and we


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are able to identify those people who need help. ”CCDHB also obtained the Child Protection Alert Certification from the Ministry of Health on 1 December 2015.

CCDHB hosted the HQSC Clinical Leadership Programme workshop pilot attended by HVDHB/CCDHB emerging Clinical Leaders on 10 December 2015 to provide feedback to inform the six Regional Workshops to be run by the HQSC in 2016 (Central Region is planned for 18 May 2016). Four senior staff attended the Overcoming Barriers to Quality Improvement – Maxine Power Workshop and met with Maxine Power and Jonathan Gray at Ko Awatea to assist in the development of an Improvement Organisational Framework at CCDHB in 2016.


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Capital & Coast District Health Boards FEBRUARY 2016

HAC PUBLIC SECTION


Author Bryan Betty

Subject Resolution to Exclude the Public

RECOMMENDATION

It is recommended that the Public be excluded from the following parts of the of the Meeting of the Board in accordance with the NZ Public Health and Disability Act 2000 (“the Act”) where the Board is considering subject matter in the following table.The grounds for the resolution is the Committee, relying on Clause 32(a) of Schedule 3 of the Act believes the public conduct of the meeting would be likely to result in the disclosure of information for which good reason exists under the Official Information Act 1982 (OIA), in particular:

Agenda Item NZ Public Health & Disability Act

Confirmation of Minutes of the previous “Public Excluded Section” of the Hospital Advisory Committee Meeting

Section 9(2)(i) of the OIA which enables the withholding of information to allow the carrying out, without prejudice or disadvantage, negotiationsSection 9 (2) (j) which enables the withholding of information to allow the carrying on, without prejudice or disadvantage, commercial activities.

Monthly Performance ReportSection 9(2) (c) enables the withholding of information to avoid prejudice to measures protecting the health or safety of members of the public.

PUBLIC Hospital Advisory Committee 12 February 2016 - OTHER

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ACUTE DEMAND MANAGEMENT – GROWTH AND POPULATION DEMANDAppendix 2.1.1 PUBLIC

1

Emergency Department attendances

Emergency Medicine is the branch of medicine that involves the diagnosis, management and treatment of acute and urgent illnesses and injuries that may be life-threatening and require immediate attention. There are three Emergency Departments (ED) in the sub-region: at WellingtonRegional Hospital in Newtown, Hutt Hospital in central Lower Hutt and Wairarapa Hospital inMasterton. An Accident & Medical Centre operates out of Kenepuru Hospital that is free for patientsthat required secondary level care but also refers to Wellington ED.

Patients arrive at ED a number of ways. They may be referred by their GP or primary healthcare provider, delivered by ambulance or they may self-present. Regardless, all patients undergo a brief triage or screening to determine the nature and severity of the illness or injury. Patients are then seen in order of urgency so those with more severe symptoms or injuries are treated before those with less serious conditions. After the initial assessment and treatment, patients may beadmitted to the hospital, transferred to another hospital or discharged.

Figure 143. ED attendance rates by DHB

Source: Ministry of Health

Figure 144. ED attendance rates bydischarge disposition


In the sub-region Wairarapa DHB had the highest Emergency Department (ED) attendance rate,followed by Hutt Valley and CCDHB. The ED attendance rate for Wairarapa residents declined 24% overfive years, converging towards the national rate, which increased five percent over the same period.Hutt Valley had a 22% increase in ED attendance rate; the rate was higher than national and diverging.CCDHB had a 21% increase in ED attendance rate; the rate was lower than national but converging.

Across all three DHBs, the rate of ED attendance for patients that were admitted as a result increased between 2010 and 2013. The overall decrease for Wairarapa was driven by the decreasing ratefor patients that are sent home (and potentially may not have needed to be seen in an ED). Theproportion of attendances resulting in admission has also increased slightly for CCDHB. The proportionof attendances resulting in admission is comparatively low for Hutt Valley – around a quarter of EDpatients were admitted in 2013 compared to over a third for Wairarapa and CCDHB.

PUBLIC Hospital Advisory Committee 12 February 2016 - APPENDICES

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2

Figure 145. Wairarapa ED attendance rates by age


Figure 146. Wairarapa ED attendancerates by ethnicity


The highest rates of ED attendance for Wairarapa residents were amongst young children aged under five years, followed by youth aged 15-24 years and people aged over 65 years. Rates declinedacross all age groups although the decrease was smallest amongst older people.

Māori in Wairarapa experienced a similar decrease to Other, although the rate was still 20%higher than Other in 2013/14.

Figure 147. Hutt Valley ED attendance rates by age


Figure 148. Hutt Valley ED attendancerates by ethnicity


The highest rates of ED attendance for Hutt Valley residents were amongst young children aged under five years and people aged over 65 years. Growth in rates was fastest amongst children five to 14 years and adults 25-44 years; however rates for these age groups were amongst the lowest. ED attendances for children aged under five grew 20% between 2009/10 and 2013/14. Allethnic groups in Hutt Valley experienced similar increases. ED attendances were highest amongstPacific people (40% higher than Other) and Māori (30% higher). The Asian rate had the fastestincrease however was still less than two-thirds that of Other.


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3

Figure 149. CCDHB ED attendance rates by age


Figure 150. CCDHB ED attendancerates by ethnicity


The highest rates of ED attendance for CCDHB residents were amongst older people aged over65 years followed by children aged under five years. Growth was fastest amongst children and all ethnicgroups in CCDHB experienced increases in rates. ED attendances were highest amongst Pacific people(30% higher than Other) followed by Māori (13% higher). The Asian rate had the fastest increase (37%between 2009/10 and 2013/14) however was still around two-thirds that of Other.

ED attendance rates by ethnicity for each age group are included in Appendix three: EDattendances. They show that:

∑ Pacific children had the highest ED attendance rates. Māori children in CCDHB had a rate similar to Other.

∑ In Wairarapa the ED attendance rate for Māori youth was slightly lower than the rate of Other. In Hutt Valley and CCDHB Māori, Pacific people and Other all had similar youth ED attendance rates.

∑ By 25-44 years, rates for Māori and Pacific people were higher than Other across all DHBs.∑ Māori aged over 65 years were the only group in Wairarapa for whom ED attendance rates

increased over the five year period.∑ In Hutt Valley, growth was fastest amongst Pacific people aged 45-64 years and Māori aged∑ over 65 years.∑ For CCDHB, ED attendance growth was relatively low for Māori and Pacific people but

faster for Asian and Other.


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4

Acute hospital inpatientsFigure 151: Acute medical & surgical inpatient rates

Source: Ministry of HealthNote: Excludes short stay ED events

Acute medical & surgical hospital admissions (excluding neonatal admissions) were higherthan the national average in Wairarapa and Hutt Valley DHBs and lower in CCDHB.Wairarapa’s rate was reasonably static between 2009/10 and 2013/14 whereas itincreased in Hutt Valley (ten percent) and CCDHB (18%). Hutt Valley’s acute inpatientrate was diverging from national and CCDHB’s was approaching national.

Figure 152. Wairarapa acute medical & surgical inpatient rates by age group


Figure 153. Wairarapa acute medical &surgical inpatient rates by ethnicity


Acute admission rates were highest amongst adults aged over 65 years in Wairarapa. They were twice as likely to be admitted acutely as children aged under five years, the group with the next highest rate. Māori had a 38% higher acute admission rate than other in 2013/14.


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5

Figure 154. Hutt Valley acute medical & surgical inpatient rates by age group


Figure 155. Hutt Valley acute medical & surgical inpatient rates by ethnicity


Acute admission rates were highest amongst adults aged over 65 years in Hutt Valley and increased11% from 2009/10 to 2013/14 (note that ED short stay events have been excluded). The rate forchildren aged under five years was particularly high; partially due to the practice of submittingpaediatric acute assessments to the National Minimum Data Set. Acute admissions for this agegroup have improved however; with a reduction in rates across most ethnic groups. Māori andPacific people had acute admission rates 33% and 43% higher respectively than Other. Therate for Pacific people has flattened, mainly due to decreases for young children andolder adults.

Figure 156. CCDHB acute medical & surgical inpatient ratesby age group


Figure 157. CCDHB acute medical & surgical inpatientrates by ethnicity



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6

Acute admission rates were highest amongst adults aged over 65 years in CCDHB andincreased14% from 2009/10 to 2013/14 (note that ED short stay events have been excluded).Acute admissions amongst young children in CCDHB have not increased (the peak in2010/11 was due to a counting change which only affected that year). Pacific peoplewere one-and-a-half times more likely to be admitted acutely as Other, and Māori had a35% higher rate. The acute admission rate for Māori increased 16% between 2009/10 and 2013/14. The Asian rate grew the most quickly, however was still around 30% lower thanOther.


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COMMS: 00051_1512

Thank you for everyone who visited the mock-up of half of Ward 6 East and provided feedback over the ten open days in December/January.Overall comments: ▪ Good design ▪ Much better design than the existing pods

▪ Natural light is fantastic ▪ Excellent use of space ▪ Staff have commented on the usefulness of the design and feedback process

For staff who missed the opportunity to view the rooms, they are still set up on

level 11 in CSB.If you have any questions or comments,

please email: [email protected]

Read a sample

of the feedback on the staff intranet

New Ward (6 East) Build Project Feedback

Appendix 2.1.2


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Trend Target Actual Target Q2 Trend Target Month Target YTD

Shorter Stays in Emergency Departments ↗ 95% 90.0% 95% 89.7% Acute Inpatient Length of Stay ↔ 3.66 4.10 3.66 3.85

Improved Access to Elective Surgery ↗ 100% 100% 100% 99.9% Elective Inpatient Length of Stay (Surgical) ↘ 4.00 3.40 4.00 3.81

Better Help for Smokers to Quit ↗ 95% 94% 95% 92% Elective/Arranged Day Surgery Rate ↔ 58% 50% 58% 53%

Target Month Target YTD Elective/Arranged Day of Surgery Admission ↔ 75% 70% 75% 72%

Number of Patient Deaths ↔ 39 306 Ward Bed Utilisation - Daily (Incl Weekends) ↘ 90% 87% 90% 94%

Severity 1 & 2 (Confirmed) ↔ 2 21 Ward Bed Utilisation - Weekdays Only ↘ 90% 88% 90% 95%

All Reported Events ↔ 816 3797 Funded Theatre Sessions Utilised ↗ 95% 98% 95% 97%

Hospital Acquired Pressure Areas ↔ 12 36 Theatre Session utilisation (Time in Theatre) ↗ 85% 82% 85% 83%

Patient Falls Causing Harm (per 1000 bed days) ↘ 80 (1.6) 409 Theatre Sessions Starting on Time U/D

Medication Errors (per 1000 bed days) ↔ 71 (0.7) 434 Acute Patients impacting on Elective Sessions ↗ 18 87

Complaints (per 1000 bed days) ↔ 32 (2.0) 428 Cancelled on Day of Surgery - Patient ↔ 19 153

Compliments (per 1000 bed days) ↔ 54 (2.9) 461 Cancelled on Day of surgery - Hospital ↗ 63 425

Cancelled on Day of Surgery - Percentage ↔ 8.5% 5.0% 8.8%

Outpatient DNA (FSA & Followup) - DNA Rate ↔ 6.0% 6.0% 6.0% 6.0%

WAITLISTS Outpatient DNA (FSA & Followup) - Maori ↔ 6.0% 17.1% 6.0% 15.3%

Target Month Booked Unbooked Outpatient DNA (FSA & Followup) - Pacific ↔ 6.0% 16.5% 6.0% 15.8%

Waiting >120 days for Treatment (ESPI5) ↔ 0 2 2 0

Waiting >120 days for Outpatient FSA (ESPI2) ↔ 0 2 2 0

Target Month Target YTD

HEALTHY WORKPLACE Dec-15 YTD Total Caseweight ↗ 5,587 5,760 34,762 35,159

Target Month Target YTD Local Acute Caseweights ↗ 2,632 2,804 16,689 17,119

Staff Turnover % (Headcount) ↔ 15.6% 20.9% 15.6% 23.9% Local Elective Caseweights ↔ 1,026 842 6,129 5,803

Sickness Absence - % Paid Hours Worked ↘ 2.3% 2.4% 2.3% 3.2% IDF Acute Caseweights ↗ 1,266 1,347 7,763 7,636

Number of Staff having >200 Hrs A/L ↘ 1,542 1,578 IDF Elective Caseweights ↗ 663 768 4,182 4,600

Physical Assaults ↔ 36 172 Outpatient FSA Volumes ↔ 3,662 3,559 22,695 23,026

Blood and Body Fluid Exposure ↔ 16 75 Outpatient FU Volumes ↔ 8,816 9,431 55,175 60,941

Slips, trips and falls ↔ 14 50 Hospital FTEs ↗ 4,285 0 4,279

Staff Appraisals (Non Medical Staff) N/A N/A Hospital Operating Costs ($'000) ↗ 54,131 56,146 332,340 340,276

Hospital Personnel inc outsourced ($'000) ↔ 35,116 35,190 215,195 216,292

MOH Targets

MOH Targets MOH Performance MeasureMOH Performance Measure Good News

CCDHBDec-15 Quarter Dec-15 YTD

VALUE FOR MONEYDec-15 YTD

Key Issue

Alert

Waitlist Patients (ESPI5 & ESPI2)

5.0%

CCDHB Monthly Balanced Scorecard December 2015KEY PERFORMANCE INDICATORS 2015/2016

CCDHB

PROCESS & EFFICIENCYPATIENT EXPERIENCE


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MHAID Service 3DHB 2015/16 FY Balanced Score Card - December


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Balanced Score Card Inpatient Units, Community Teams and Indicator Definitions

The MHAID Service 3DHB is comprises two main parts:

∑ The local/sub-regional mental health and addiction services.

∑ Te Korowai-Whāriki which consists of adult rehabilitation and forensic (mental health and addiction) and intellectual disability services.

A range of age specific community and inpatient services are delivered to meet population needs.

Eleven inpatient units provide service and age specific assessment and treatment for the most severely unwell consumers. Services are either local, sub-regional regional or national (see table 1). The balanced score card inpatient measures are divided by DHB for the local/sub-regional services. For Te Korowai- Whāriki the inpatient measures split is by Forensic & Inpatient Rehabilitation and Intellectual Disability. There is additional split by age-based facilities for forensic and intellectual disability services.

Table 1. MHAID Service 3DHB Inpatient UnitsMHAIDS 3DHB

Group Provision* Service & Age Focus** Hutt Valley DHB Capital and Coast DHB

Loca

l / S

ub-R

egio

nal Intensive

Recovery Sector

Sub-regional Mental Health - Adult ∑ Te Whare Ahuru∑ Te Whare o Matairangi∑ Managed Withdrawal Service beds

Central region Mental Health - Adolescent ∑ Regional Rangatahi Acute Inpatient Unit

Sub-regional Mental Health - Psychogeriatric ∑ Te Whare Ra Uta

Younger Persons Community & Addictions

Central region Eating Disorders - Mixed ∑ Central Region Eating Disorder Service

Te K

orow

ai-W

hārik

i Forensic & Inpatient Rehabilitation

Central region Regional Rehabilitation - Adult ∑ Tawhirmatea ∑ Tane Mahuta

Central region Forensic - Adult∑ Puraehuraehu ∑ Rangipapa

National Forensic - Youth ∑ Nga Taiohi Build in progress

Intellectual Disability Services

Central and South Island Intellectual Disability - Adult ∑ Haumietiketike

National Intellectual Disability - Youth ∑ Hikitia Te Wairua

* Sub-Regional Wairarapa, Hutt Valley, Capital and Coast DHBs; Central Sub-Regional DHBs plus Mid-Central, Hawkes Bay, Wanganui DHBs plus Tairawhiti DHB; National All DHBs** Youth Population aged 12 – 18 years; Adult Population aged 18 – 65 years; Psychogeriatric Population aged 18 – 65 years; Mixed Population aged 16 plus years


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There are 61 community based provider arm teams (see table 2). The majority are local or sub-regional services providing primarily assessment and treatment. Some teams also provide consultation liaison and education services. The balance score card community indicators report performance for these teams. Given varying indicator definitions not all teams are reported in all the measures (MHAID Service 3DHB, 2015).

Table 2. MHAID Service 3DHB Community Provider Arm ServicesMHAIDS 3DHB

Group WDHB HVDHB CCDHB

Loca

l / S

ub-R

egio

nal

Younger Persons Community & Addictions

∑ CAMHSa ∑ CAMHS teams: Child Speciality Service and Youth Speciality Servicea

∑ Intensive Clinical Service Teamb

∑ Central Region Eating Disorder Service – CommunityC

∑ CAMHS teams: Kapiti, Porirua, Wellington, Primary Liaison Service, Pasifika and Maoria

∑ Early Intervention Serviceb

∑ Specialist Maternal Mental Health ServiceC

Adult Community & Addictions

∑ Adult CMHTa ∑ CMHTs: 1, 2, 3 and 4a

∑ Detoxa

∑ Older Persons Mental Health Servicea

∑ CMHTs: Kapiti, Porirua, South and Wellington, Adult Maori, Adult Pasifikaa

∑ Co-Existing Disorder Service b

∑ Community Alcohol and Drug Servicea

∑ GP Liaison: Kapiti, Poriruaa

∑ GP Opioid Serviceb

∑ ECTa

∑ Managed Withdrawal Serviceb

∑ Psychogeriatric teama

∑ Opioid Treatment Service∑ Regional Personality Disorder ServiceC

Intensive Recovery Sector

∑ Acute Day Servicea

∑ CATTa

∑ Consultation Liaisona

∑ CATTa

∑ Consultation Liaisona

∑ Home-based Treatmenta

∑ Rangatahi Day Servicea

∑ Rangatuhi Day Servicea

∑ TACTa

Operations Centre

∑ Intake Teama

∑ MH NASCa∑ Te Haikaa

∑ Service Coordinationa

TeKo

row

ai-

Whā

riki

Forensic & Inpatient Rehabilitation

∑ Adult Forensic Community ServiceC

∑ Regional Adult Forensic Community ServiceC

∑ Youth Forensic Community ServiceC

Intellectual Disability Services

∑ Co-existing Mental Health & Intellectual Disability Serviceb

∑ Behavioural Support Service b

∑ National Intellectual Disability Care Agencyd

aLocal: Primarily delivered to respective DHB population. bSub-Regional Wairarapa, Hutt Valley, Capital and Coast DHBs (some services only contract delivery to Hutt Valley and Capital and Coast DHBs); cCentral Sub-Regional DHBs and Mid-Central, Hawkes Bay, Wanganui DHBs (some contracts also include Tairawhiti DHB); dNational All DHBs


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Table 3. MHAID Service 3DHB Balanced Score Card Indicator DefinitionsNo. Measure Target Definition Purpose and utility of indicator Reporting capability

1.1 28 day readmission rate

(Adult IP units only)

Target - 10%

Alert - ≥20%

Total number of in-scope overnight referral closures by the participant’s acute mental health and addiction services inpatient unit during the reference period that are followed by a readmission within 28 days to the organisation’s acute mental health and addiction services inpatient unit. Excludes transfers, deaths & readmissions from same day event (Northern DHB Support Agency, 2010).

Unplanned readmission to an inpatient service following a recent discharge may indicate that inpatient treatment was either incomplete or ineffective or that follow-up care was inadequate to maintain the person out of hospital.

WDHB: N/A as no IP unit.

1.2 Long-term consumers with current wellness plan (%)

95% The percentage of long-term consumers with a wellness plan. Long-term consumers are adults and older people (20 years plus) whose episode of care is two or more years, and children and youth whose episode of care is for one or more years. The episode of care is measured from the inpatient admission or primary community referral start date (Ministry of Health, 2014a).

A proxy measure for quality of care. Wellness plan (relapse prevention plans) identify early relapse warning signs of clients. The plan identifies the support required by the tangata whaiora/consumer to promote resilience and recovery when early warning signs are present. Each client will know of (and ideally have a copy of) their plan.

WDHB: manual quality audit

HVDHB: Report on current electronic risk plans

CCDHB: Report on electronic wellness plans

1.3 Held for indicator under development

1.4 Better help for inpatient smokers to quit

95% The percentage of hospitalised patients who smoke and are seen by a health practitioner in public hospitals and percentage of enrolled patients who smoke and are seen by a health practitioner in general practice are offered brief advice and support to quit smoking (Ministry of Health, 2014b).

There is strong evidence that brief advice is effective at prompting quit attempts and long-term quit success. The quit rate is improved further by the provision of effective cessation therapies –pharmaceuticals, in particular nicotine replacement therapy (NRT), and telephone or face-to-face support.


1.5 HoNOS compliant inpatient discharges -matched pairs

≥80% The percentage of in scope discharges that have both an admission and discharge HoNOS. In scope discharges: LOS >3 days and the consumer was discharged routinely or to another healthcare facility OR to other service within the same facility. The consumer was not discharged to another psychiatric inpatient unit or an accident and emergency service (Northern DHB SupportAgency, 2010; Te Pou, 2012).

Provides information about the effectiveness of inpatient treatment in aiding recovery by measuring if change occurs between the admission and discharge HoNOS.


HVDHB: Snapshot

CCDHB: New measure –covers the reference period. Data validation still required.


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No. Measure Target Definition Purpose and utility of indicator Reporting capability

1.6 HoNOS collection compliance -community

≥80% Number of community consumers with a current HoNOS collection. In-scope collections are within the current episode of care. For new referrals the collection must be within 14 days of the first face-to-face appointment. Thereafter a 91 day review is required. The 91 day reviews are required to be completed within 14 days either side of the review date (Te Pou, 2012).

Provides information about the effectiveness of community treatment in aiding recovery by measuring if change occurs overtime.

WDHB/HVDHB: Snapshot

CCDHB: New measure –covers the reference period. Data validation still required.

1.7 Consumer death by suspected suicide (community and inpatient)

N/A Count of suspected community suicides by current mental health consumer within 28 days of contact with service and all suspected suicides as inpatient (Health Quality and Safety Commission New Zealand, 2012).

1.8 Severity 1 & 2 (Confirmed SAC 1&2)

N/A Count of the number of SAC 1&2 events that have been reviewed and reported by the CCDHB Patient Safety Office per month (Health Quality and Safety Commission New Zealand, 2012).

Serious Adverse Events are events which have generally resulted in harm to patients. When adverse incidents occur, it’s important these events are reported, investigated and reviewed so we can learn from them and improve the way we do things. Systematic review of and learning from adverse events should see a reduction in serious adverse events over time, reflecting improved safety for people using services (Mental Health Commission, 2014).

1.9 All reportable events

N/A Count of the number of all reported events reported in the reportable events database prior to any review.

1.10 Medication errors (n)

Count of the number of all medication errors reported in the Reportable Events system.

1.11 Complaints (n) Count of the number of complaints received and recorded per week by the Quality & Risk team and reported in the reportable events database.

1.12 Complaints resolved/closed within 30 days (%)

100% complaints resolved within 30 days

The percentage of all complaints that were received in the reference period and resolved in 30days. This excludes HDC complaints or where the complainants have been notified within 10 working days that an extension is required by the DHB which received the


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complaint (HDC Code of Health and Disability Services Consumers’ Rights Regulation 1996, n.d).

1.13 Health & Disability Commissioner Complaints

Count of all HDC complaints in the reference period and year to date

1.14 Compliments (n) Count of the number of compliments received and recorded per month by the Quality & Risk team in the reportable events database.

1.15 Restraints (n) Count of the number of all restraints reported in the Reportable Events system.

1.16 Consumers required to undergo MH Act assessment

Count unique consumers required undergo assessment subject to sections 11 or section 13 or section 14(4) of the Mental Health Act during the reference period.Consumers transferred between sections in the reference period are only counted once. If section 11 has occurred more than once in the reference period, the person is counted twice.

WDHB: Manual data

All DHBs: Data quality issues that each DHB is working on may impactnumbers. Data quality project underway.

1.17 Consumers subject to compulsory treatment order

Count of unique consumers subject to an inpatient or community compulsory treatment order during the reference period. This includes extensions and indefinite orders. Consumers transferred between sections in the reference period are only counted once. For example an inpatient treatment order transferred to an outpatient treatment order or when an order is extended or made indefinite. Per the national health target and DHB Maori Health Plans, this indicator also reports the number of Maori subject to section 29 community treatment orders (Capital and Coast District Health Board, 2014; Hutt Valley District Health Board, 2014; Wairarapa District Health Board, 2014).

As above

1.18 Number of seclusion hours

Count of the hours that are attributed to seclusion activity in the reference period. This measure excludes


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per 100000 pop. the hours attributed to events that occur before or after the reference period. The divisor is DHB catchment projected population divided by 100,000. The Maori and Pacific projected populations are the divisor for the supplementary measures.

2.1 Access rate The average total number of people domiciled in the DHB region, seen per year rolling every three months being reported (the period is lagged by three months) for the projected population of the DHB region (Ministry of Health, 2014c).

This indicator will provide a means of monitoring rates of access to assessment and treatment services and to compare these with what is known about the distribution of mental disorders and what is aimed for in policy and in funding agreements.

It is known that there are significant levels of unmet need in mental health and addiction. A measure Is required to monitor population treatment rates and assess these against what is known about the distribution of mental disorders in the community(Mental Health Commission, 2014).

Ministry of Health data, incudes NGOs. Rolling year, 3 month lag (PP6).

2.2 Average length of acute inpatient stay (days)

14-21 days

Alert - ≥30 days.

Total number of inpatient bed nights for discharges that occurred in the reference period – excludes transfer, deaths and leave days (Northern DHB Support Agency, 2010).

Mental health & addiction services aim to provide care in the least restrictive environment. This KPI provides some information about the extent to which this is being achieved and promotes a more complete picture of an organisation’s overall model of care(Northern DHB Support Agency, 2012).

2.3 Inpatient occupancy

85% Average level of occupancy in acute inpatient units managed by the mental health and addiction service over the reference period (Northern DHB Support Agency, 2010).

Most acute inpatient units run at or close to 100%.Experience suggests that acute inpatient units operating above 90% occupancy on an ongoing basis are stressed, compromising the provision of optimal care during the inpatient period including discharge planning.

Benchmarking will help to understand variations between DHBs, the drivers of high occupancy, and may support movement toward lower occupancy rates (Mental Health Commission, 2014; Northern DHB Support Agency, 2010).

2.4 Pre-admission 75% Number of in-scope acute inpatient referrals to the Provides a measure of the quality of care, efficiency of HVDHB/CCDHB: New


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community care mental health and addiction service organisation’s acute inpatient team, occurring during the reference period for which a face-to-face community mental health contact was recorded in the seven days immediately preceding that admission by community care services managed by the organisation (Northern DHB Support Agency, 2010).

resource use and the extent to which a service has engaged with consumers and attempted to support them within their natural environment (Northern DHB Support Agency, 2012).

measure. Data validation still required

2.5 Post-discharge community care

90% Number of overnight referral closures from acute inpatient units to the organisation’s community catchment during the reference period for which a community mental health contact with client participation was recorded in the seven days immediately following that discharge (Mental Health Commission, 2014; Northern DHB Support Agency, 2010).

A responsive community support system for people who have experienced an acute psychiatric episode requiring hospitalisation is essential to maintain clinical and functional stability and to minimise the need for hospital readmission (Northern DHB Support Agency, 2012).

Refer to comment 2.4.

2.6 Consumer related time

30-40% The percentage of recorded community clinical activity that is attributed to paid direct-care clinical FTE in the reference period. The numerator is the total recorded clinical activity for both consumer participation time (telephone & face-to-face) and non-consumer participation time (liaison/care coordination with other agency or family contact without the consumer present). The denominator 'paid direct-care clinical FTE' is all paid hours for staff (excludes support and management/administration staff) minus any recorded leave (Northern DHB Support Agency, 2010).

Number of contact hours with service user participation plus the number of contact hours without service user participation (Northern DHB Support Agency, 2012).

WDHB/HVDHB: Indicator under development.

2.7 Community treatment days per quarter

10-12 days Total number of community treatment days provided by the mental health and addiction service organisation’s community mental health and addictions services within a three month reference period. (A treatment day is a day on which a service user received some clinical input; it could be one contact or many). This is a three monthly average (Northern DHB Support Agency, 2010).

Provides a measure of the intensity of treatment within the community (Northern DHB Support Agency, 2012).

WDHB/HVDHB: Indicator under development.

2.8 Wait-time to first face-to-face

80% < 3 weeks

Measures Wait-time from the referral received date to the first face-to-face appointment.

Provides a measure of service efficiency (Ministry of Health, 2014c).

Ministry of Health data, Rolling year, 3 month lag


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contact 95% < 8 weeks

The MHAID 3DHB calculation differs slightly to the MoH PP8 measure as we measure the wait-time for all referrals. The MoH calculation measures wait times for those consumers who have not access MH&AS in the past year.

(PP8).

2.9 Community DNA rate

Count of DNA activity. The count divided by all DNA activity plus all face-to-face activity in the reference period provides the DNA rate.

Note: In MHAID mental health & addiction services did not attend activity (DNA) is mainly collected as an activity, rather than an appointment as used by the 3-DHB general outpatients measure This means that the general out patients and MHAID measure is not comparable.

Provides a measure of the quality of care (safety and risk for consumers who do not attend) and efficient use of community FTE resource.

HVDHB/CCDHB: New indicator.

2.10 Caseload with consumer participation in the last 90 days (%)

All unique community consumers at month end, with an episode of care 90 days or over, that have had a service user participation contact recorded during the previous 90 days.

An indicator of service delivery timeliness and proxy measure to consider if active treatment is being delivered to consumers accessing community teams (Mental Health Commission, 2014).

3.1 Staff turnover –annualised (%)

8-10% Number of employed staff who voluntarily resign from mental health and addiction services within the reference period (Northern DHB Support Agency, 2010).

Provides an indicator of the effectiveness of staff recruitment, orientation, engagement and support. Overall it is generally seen as an indicator of the health of the organisation (Northern DHB Support Agency, 2012).

Annualised indicator from October 2015

3.2 Sick leave (%) 2-4% Total number of sick leave hours claimed by all employed mental health and addiction staff during the reference period (Northern DHB Support Agency, 2010).

Provides an indicator of a healthy, sustainable workforce (Northern DHB Support Agency, 2012).

3.3 Number of staff with annual leave > 200 hours (n)

0

(Coop, 2006)

Total number of MHAID staff who have annual leave owing greater than 200 hours during the reference period (Coop, 2006).

Provides measure and control on annual leave liability. Staff are encouraged to take leave for their better wellbeing, in turn this reduces the liability carried by the organisation (Coop, 2006).

3.4 Physical assaults Count of assaults.


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on staff

3.5 Percentage of performance appraisals completed

100%

(Coop, 2006)

Percentage of performance appraisals completed in the last year excluding causal, fixed term, medical.

This indicator signals the significance of staff career development and progress towards high quality service delivery (Coop, 2006).

CCDHB: Underdevelopment

4.1 Operating (actual) costs ($'000)

Total MHAID costs including personnel, outsourced, clinical costs, infrastructure costs and recharging during the reference period (Coop, 2006).

Provides measure on total cost over total revenue. In general a good indicator to have some controlled measures by percentages etc.

4.2 Personnel including outsourced ($'000)

Total MHAID personnel and outsourced costs during the reference period (Coop, 2006).

Provides an indicator of personnel costs and outsourced costs percentages to total revenue. Good indicator to measure performance on budget.

4.3 Overtime (total hours versus overtime hours)

Total overtime hours costs over total hours of personnel costs (Coop, 2006).

An indicator of total overtime hours spent compared to total personnel hours costs. This gives a good picture on the use of overtime hours and puts control measures as percentage to total hours. In general a good tool to control overtime costs over budget.

4.4 FTEs - actual Total MHAID personnel and outsourced FTE’s (contracted), excluding vacancies during the reference period (Coop, 2006).

Measure the performance vs budget.

4.5 FTEs - vacancies Manual count of vacancies provided on a monthly basis, one month lag.


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References

Capital and Coast District Health Board. (2014). Capital & Coast District Health Board Maori Health Action Plan 2014/15. Retrieved from http://www.ccdhb.org.nz/planning/Maori_Health/CCDHB Maori Health Plan 2014_15_FINAL.PDF

Coop, C. F. (2006). Balancing the balanced scorecard for a New Zealand mental health service. Australian Health Review : A Publication of the Australian Hospital Association, 30(2), 174–80. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/16646766

Health Quality and Safety Commission New Zealand. (2012). Serious Incidents involving users of Mental Health services. Retrieved February 02, 2015, from http://www.hqsc.govt.nz/assets/Reportable-Events/Publications/Reporting-reviewing-adverse-events-MH-Dec-2012.pdf

Hutt Valley District Health Board. (2014). Hutt Valley District Health Board Maori Health Plan 2014/15. Retrieved July 15, 2015, from http://www.huttvalleydhb.org.nz/content/3e4af01f-de2c-426a-80a5-dc0ffbcf43a7.cmr

Mental Health Commission. (2014). MHC (Rising to the Challenge) Outcomes Framework - Outcomes Framework Indicators Definition Draft V3.0 (20th June 2014).

MHAID Service 3DHB. (2015). Mental Health, Addictions & Intellectual Disability Service 3DHB: Balanced Score Card - Technical Specifications (in draft).

Ministry of Health. (2014a). 2013/14 DHB non-financial monitoring framework and performance measures. Retrieved February 02, 2015, from http://www.nsfl.health.govt.nz/apps/nsfl.nsf/pagesmh/508

Ministry of Health. (2014b). 2014/15 DHB Health Targets. Retrieved February 02, 2015, from http://www.nsfl.health.govt.nz/apps/nsfl.nsf/menumh/Accountability+Documents

Ministry of Health. (2014c). 2014/15 DHB non-financial monitoring framework and performance measures. Retrieved February 02, 2015, from http://www.nsfl.health.govt.nz/apps/nsfl.nsf/menumh/Accountability+Documents

Northern DHB Support Agency. (2010). Key Performance Indicator Framework for New Zealand Mental Health and Addiction Services Phase III: Implementation of the Framework Benchmarking Participation Manual Part 3. Technical Specifications for participating organisations July 2010. Retrieved February 02, 2015, from http://www.ndsa.co.nz/LinkClick.aspx?fileticket=oBs7TAI8s_Q=&tabid=95

Northern DHB Support Agency. (2012). KPI Framework for New Zealand Mental Health And Addiction Services. Phase III - Implementation of the framework in adult mental health services. June 2012. Retrieved December 11, 2014, from http://www.ndsa.co.nz/OurServicesWhatWeDo/MentalHealth/KPIFramework.aspx

Te Pou. (2012). Mental Health Outcomes Information Collection Protocol - HoNOS Family (Version 2.1). Retrieved February 02, 2015, from http://www.tepou.co.nz/library/tepou/mental-health-outcomes---information-collection-protocol

Wairarapa District Health Board. (2014). Wairarapa District Health Board Maori Health Action Plan 2014/15. Retrieved from http://www.huttvalleydhb.org.nz/content/df930e87-ed92-404d-a0d0-dc2d30a31d34.cmr


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Appendix 2.2.2 PUBLIC

1 | P a g e

DATA ON SUICIDE

The national figures (from the coroner) are for the year July to June.

When referring to DHBs the Coroner gives figures for people residing in the DHB regions (not those in treatment by a DHB Mental Health/Addiction Service).

Rates given are per 100,000 population calculated following Statistics New Zealand annual population estimates.

Page 2 and 3: National Data.

Page 4, 5, 6 and 7: MHAID Service 3DHB (for those in treatment by a DHB Mental Health/Addiction Service either inpatient or community).

For the three years, 2013, 2014 and 2015, 45 clients of the Service in Hutt and CCDHB committed suicide. In these regions for 2013, 2014 and 2015 there were 149 suicides. 70% of those in the Hutt Valley DHB and CCDHB region who committed suicide were not clients/did not have contact with MHAID Service 3DHB.

For Wairarapa, in the three years 2013, 2014 and 2015 there were 27 suicides. MHAID Service 3 DHB began collecting data from February 2015. From July 2014 to June 2015 there were 9 suicides in the Wairarapa, 2 were Service clients.


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2 | P a g e

NATIONAL


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3 | P a g e


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4 | P a g e

CCDHB and HVDHB Data on Suicides for 2013 to 2015 The figures are for calendar year.

The DHBs are reliant on notification of suicides via Regional Public Health (Regional Suicide Postvention Coordination), or through our own reporting systems where the DHB has direct knowledge of the event.

Currently Regional Suicide Postvention Coordination is only able to provide data on suicides in the CCDHB and HVDHB region. No data was available for Wairarapa. Systems are being put in place to capture this data by RSPC.

MHAIDS 3DHB figures are for clients of our service, or people who had recent contact with our service and went onto suicide.

Suicides by year and DHB for clients of Mental Health/Addiction Services. 2015 saw a rise in suicides for both HVDHB and CCDHB. Causational factors for the overall trend are unknown. Factors at the individual level are multiple and varied.


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Suicides by gender and DHB for clients of Mental Health/Addiction Services. The ratio for female to male suicides during 2013 to 2014 was approximately 2:1 and 1:2 respectively. During 2015 there was a increase in the number of reported male suicides with a ratio of 1:3. Causational factors for the overall trend are unknown.


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6 | P a g e

Age Female Male Total

10-14 1 0 1

15-19 2 3 5

20-24 0 3 3

25-29 2 4 6

30-34 2 1 3

35-39 4 1 5

40-44 5 3 8

45-49 0 6 6

50-54 0 2 2

55-59 1 1 2

60-64 0 2 2

65-69 1 1 2

70-74 0 0 0

75-79 0 0 0

80-84 0 0 0

85+ 0 0 0

TOTAL 18 27 45

Suicides by gender and age 2013 to 2015 for clients of Mental Health/Addiction for HV DHB & CCDHB. The national ratio of female to male suicides for 2014/15 is approximately 1 to 3. Suicides for HV and CCDHB are closer to a 1:2 female to male ratio.


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Suicides by Ethnicity 2013 to 2015 for clients of Mental Health/Addiction HVDHB & CCDHB. The proportion of suicides by people of Maori ethnicity when compared with the rest of the population in HV DHB &CCDHB clients is lower (13.3%) than what is seen nationally for the overall population in the Coronial figures.


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Communication is the aspect of our care most patients (61%) say makes a difference to the quality of their care and treatment.

“I was kept informed of what was happening, where I was being moved to, etc.”

How are we doing on communication?

7 75

Poor Moderate Very Good

For nearly half of all our patients (43%), being treated with compassion, dignity and respect is one of the top three things that matter to the quality of their care and treatment.

“Resting time was not respected at all. The nurses and staff members at the reception desk were chatting and yelling all the time quite loud...it made it quite difficult to sleep and rest properly.”

How are we doing on dignity and respect?

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Four out of every 10 patients (41%) rate feeling confident about the quality of their care and treatment as one of the things that make the most difference.

“Nothing felt rushed, everything was explained, everyone was professional.”

How are we doing with patients feeling confident about their care and treatment?

4 83


How patients rate their overall care and treatment Each month CCDHB patients are asked to rate their overall care and treatment. An average of 87 per cent of patients between October 2014 and September 2015 rated their care and treatment as very good or excellent. Around one per cent rated it as poor. These ratings are consistent over time.

Patients who rate their treatment as very good or excellent (%)

Overall n=3553 (October ’14 – September ’15)

86 86 86 87 87 86 87 86 86 87 87 87

70

80

90

100

Understanding Patient Experience Listening to our patients’ experience is essential to understanding how we can improve the care we deliver and provide a patient-centred health service.

The CCDHB in-Patient Experience Survey focuses on the dimensions of care that make the most difference to patients’ care and treatment, and tells us how we are performing on each of those dimensions.

To date more than 7,500 patients have taken part.

How patients rate what matters Patients are asked to rate CCDHB’s performance on 11 dimensions of care, on an 11-point scale where 0 is `poor’ and 10 is `excellent’.

The graph below ranks the dimensions of care in order of what matters most to patients and shows how we are doing on each of those dimensions. The percentages of patients who say that each dimension makes a difference to their care and treatment are listed next to each.

Overall care and treatment ratings (%)

7

4

4

8

6

5

6

12

21

4

38

11

75

84

83

71

73

76

77

70

58

83

35

69

Communication (discuss care and treatment)

Treated with compassion, dignity and respect

Confidence about the quality of care &…

Consistent and coordinated care while in…

Getting good information

Involvement in decisions about health and…

Managing pain and nausea

Cleanliness and hygiene

Co-ordination between hospital, home &…

Enabling whānau, family and friends support

Food and dietary needs

Values, beliefs and cultural needs met


61%

43%

41%

37%

30%

23%

20%

13%

11%

7%

6%

2%

matters %

Report on

R epo rt

October 2015

20 Summary Report: Capital and Coast District Health Board

Patient Experience

CCDHB Patient Experience Report no.20 October 2015: 1

Our patients are asked to choose the three things that matter most to their care and treatment.

APPENDIX 2.4.1


73

“I felt in safe and caring hands, this included the lovely ladies who were there to show us where to go. The nurses communicated throughout as there was a bit of a delay. The Doctor told me exactly what he was going to do and I felt in safe hands. The nursing staff in theatre could not be faulted and everyone supported me throughout. My husband (who was also impressed with the staff) was waiting for me and the staff kept him informed (and provided us both with a cuppa afterwards).” “I always felt that I was being kept up to date with test results, why tests were being done and what the results meant. [One doctor] in particular had a very effective communication style and as a Māori patient I appreciated his use of Te Reo Māori in communicating with me.”

“Everyone one we were involved with listened and shared their time and knowledge, we could not fault them.”

Focus Area: Communication Our focus this month is on communication, which is the aspect of care most CCDHB patients (61%) say matters most to their care and treatment

PERCENTAGE OF STAFF WHO TALK TO PATIENTS ABOUT THEIR CONDITION AND TREATMENT IN WAYS THAT ARE EASY TO

UNDERSTAND.

Doctors n=3466; Nurses/Midwives n=3308; Administration n=2302; Allied staff n=1871. The differences are significant (p<0.05).

PERCENTAGE OF PATIENTS WHO FEEL THEY ALWAYS HAVE ENOUGH TIME TO DISCUSS HEALTH AND TREATMENT WITH CLINIC STAFF

Doctors n=3396; Nurses/Midwives n=3158; Administration n=1815. The differences are significant (p<0.05).

PERCENTAGE OF PATIENTS WHO SAY STAFF ALWAYS LISTENED TO WHAT THEY HAD TO SAY

Doctors n=3327; Nurses/Midwives n=3243; Administration n=1905.

79

78

69

71

Doctors

Nurses or midwives

Administrative or Reception staff

Allied staff

71

77

71

Doctors

Nurses or midwives


79

79

77

Doctors

Nurses or midwives


“Doctors communication was excellent but a number of the nursing staff did not seem to understand my questions nor my requests. Quite a few times, nursing staff would disappear, never to return after I had made a request e.g. pain medication, a blanket, follow up of reading vitals......they just never came back...”

“The communication between the staff and our family was great and we knew exactly what was happening etc. However the communication between the different teams of staff has room for improvement.”

“I saw doctors from multiple departments. They would come and see me and then say they'll be back after talking to their boss and not one ever returned. There was zero communication between departments with each one saying my problem was caused by something different and no one wanted to admit it was their department that should be treating me.”

About the Patient Experience Survey

The CCDHB In-Patient Experience Survey is online. An email containing a survey link is sent to patients between one and two weeks after they have been discharged from hospital. They are asked about their most recent experience in hospital.

On average, just under one-quarter (23%) of CCDHB patients complete the survey, with 30 per cent completing or partially completing the survey.

This report is prepared independently of CCDHB by Point and Associates Limited.

For more information on the patient experience survey, contact Catherine Gibson, [email protected] or (04) 806 0724

CCDHB Patient Experience Report no.20 October 2015: 2

Our patients are asked to rate communication on a scale of 0-10 (where 0=poor and 10=excellent).

APPENDIX 2.4.1


74

mailto:[email protected]

Full spread page 1

Full spread page 3

Health Targets There are six national health targets set by the Ministry of Health to track how well district health boards are providing services to their communities. The targets include both preventative health and hospital service measures and are publically reported each quarter.

We have a number of programmes in place designed to help us meet the targets, however improving the target results will take an all of health sector approach. Because of this the DHB is building on its already strong relationship with primary and community based health care. We want to work proactively to ensure that people are getting the services, check-ups and information they need to help them to stay well.

HealtH target target2014/15

Q4 results achievement

increased immunisation The target is 95% of eight month olds have their primary course of immunisation at six weeks, three months and five months on time.

95% 95%

Achieved

imProVed access to electiVe surgerY The target is an increase in the volume of elective surgery by at least 4000 discharges per year. 100% 101%

Achieved

sHorter staYs in emergencY dePartments The target is 95% of patients will be admitted, discharged, or transferred from an emergency department (ED) within six hours.

95% 95%

Achieved

Faster cancer treatment The target is 85% 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.

85% 81%Good

progress is being made

better HelP For smokers to Quit The target is 95% of patients who smoke and are seen by a health practitioner in public hospitals are offered brief advice and support to quit smoking.

95% 92%Good


The target is 90% of patients who smoke and are seen by a health practitioner in primary care are offered brief advice and support to quit smoking.

90% 88%Good


more Heart and diabetes cHecks The target is 90% of the eligible population will have had their cardiovascular risk assessed in the last five years.

90% 89%Good


Quality and Safety Markers The Health Quality & Safety Commission is driving improvement of New Zealand’s health care through the national patient safety campaign ‘open for better care’. The quality and safety markers below help evaluate the success of the campaign nationally.

A glimpse into Capital & Coast DHB

marker deFinition

nZ goal

Jul to sep 2014

oct to dec 2014

Jan to mar 2015

apr to Jun 2015

ccdHb comparison with nZ goal

PreVenting Patient Falls: Percentage of patients aged 75 and over (Māori and Pacific Islanders 55 and over) that are given a falls risk assessment.

90% 83% 83% 87% 92%

PreVenting Patient Falls: Percentage of patients assessed as being at risk have an individualised care plan which addresses their falls risk.

90% 92% 96% 91% 95%

saFe surgerY: Percentage of operations where all three parts of the surgical checklist were used.

90% 95% 99% 98% 99%

reducing surgical site inFections: Right antibiotic in the right dose - 2 grams or more cefazolin given or 1.5g or more of cefuroxime.

95% - 99% 98% 98%

reducing surgical site inFections: Appropriate skin antisepsis in surgery using alcohol/chlorhex or alcohol/providone iodine.

100% - 99% 100% 100%

reducing surgical site inFections: Antibiotic given (0-60 minutes before “knife to skin”. 100% 99% 98% 96% 100%

imProVing Hand HYgiene: Percentage of opportunities for hand hygiene for health professionals.

80% 76% 76% 72% 79%81% achieved

in July-Sept 2015

FEEDBACK: We welcome your feedback on how we can improve our ccdHb Quality accounts. Please email [email protected].

Talofa lava

Welcome

Nau mai, haere mai

Welcome to our annual publication aimed at providing our community with examples of how we have been improving our services supporting their health needs during 2014/15.

Quality Accounts 2014/15

INSIGHT:What We Do We receive funding to improve, promote and protect the health of the people within the Wellington, Porirua and Kapiti regions. We have an annual budget of more than $900 million which we use to provide health services as well as contracting external providers, such as general practices, rest homes, and pharmacists, to deliver care. Our district health board is the sixth largest in New Zealand with just over 300,000 people living in the district. We are also the leading provider of a number of specialist services, including neurosurgery, oncology, neonatal intensive care, and specialised mental health services, for the upper South and lower North Islands. We also provide specialist intellectual disability services for the whole country.We operate the Wellington Regional Hospital, Kenepuru Community Hospital in Porirua, Kapiti Health Centre in Paraparaumu, and a large mental health campus based at Porirua. We also provide a range of community-based services including district nursing, rehabilitation services, social work, alcohol and drug services, and home support services. Over 4300 full-time equivalent staff work at Capital & Coast District Health Board. The people of the Greater Wellington region enjoy, on average, better health, longer life spans, and lower rates of morbidity and mortality than many other parts of the country.

On an average day:

COM

MS:

000

07-1

512.

1

Malo ni

Malo e lelei

Kia orana

Bula vinaka

Kia Ora

people present to the emergency department at Wellington Regional

Hospital

154

2220patients are seen by a GP

201people have a

heart and diabetes check at their GP hospital appointment

letters are sent to patients

708

patients are visited by a

district nurse

229

164patients are admitted to

our hospitals

patients are flown to, or from Wellington Regional

Hospital

6

76people are offered

support to quit smoking by a health

professional

prescriptions are filled by community pharmacies

9750

59patients undergo surgery

hospital meals are served to

patients

1900

babies are born

10infants are cared for

in Wellington Regional Hospital’s Neonatal Intensive Care Unit

(NICU)

33

2189people are cared for in aged

residential care

Appendix 2.4.2


75

Improving health & disability services in our regionAn overview of Capital & Coast DHB’s 2014/15 priorities

approximately half of new Zealanders have poor health literacy,

which is the ability to obtain and understand basic health information.

Children of parents with poor health literacy face even greater barriers to accessing the health care they need.

We reviewed how we communicate with the whānau of patients using our child health services and found the language is

inconsistent and contains a lot of technical jargon. For example, we talk about referring to a ‘consultant’ while GP practices

use ‘specialist’. We also noticed that if the specialist was referred to as Mr or Mrs, people often didn’t understand they were a doctor.

We also walked from the front of the hospital through to the children’s clinic – mirroring what children and their whānau do when they come to see us. It’s a long walk and the clinic is not

easy to locate or describe if people ask for directions. We have rewritten the appointment letters using everyday

words to make them easier to understand. Extra signage has been added to make the children’s clinics easier

to find. The learnings from this review will be applied to other services as well.

PATIenT AnD whānau centred care

Zero patient harm

Preventing falls is as important in

hospital as it is in the community.A third of people aged over 65 will have

a fall at least once a year. Someone who falls is then two to three times more likely to fall again

within a year. The impact of falls is serious as people can lose confidence due to their fear of falling again.

Our falls prevention programme is making a difference, and harm caused from falls when people are in hospital is reducing.

Last year we had seven months when no patients had a serious falls injury while in hospital.

Regular exercise is one of the best things you can do to help stand up to falls. ACC, Sports Wellington, and Wellington Free Ambulance are working with health professionals from hospital and in the community

to focus on keeping people moving safely.

To improve patient

care the Wairarapa, Hutt Valley and capital & coast district Health boards’

mental health, addiction and intellectual disability services now operate as a single service.

This is the first time district health boards have worked together to combine their individual mental health services and is

a flagship innovation for New Zealand. By integrating services we have been able to provide more help to people in the greater Wellington region. For example the younger persons & addictions group is now caring for clients up to 25 years

of age. Previously this service was only available to people aged 17 – 19 years old.

Another example is Te Whare Ra Uta, the psychogeriatric unit located at Porirua. This service was previously only available to people living in the Capital & Coast DHB region. The service has been expanded and people

from Hutt Valley are now able to access specialist mental health care for older people.

Through regional collaboration we have been able to create a service with no boundaries so clients can access the care they need, irrespective of where in the region they live

or where the service is provided.

If you are concerned about

your own or a loved ones mental wellbeing, you can phone 0800 745 477 any time of the day or night for support or advice.

A new initiative is making it easier for patients to get health care

closer to their home rather than travelling to hospital for treatment.

The initiative called ‘primary options for acute care’ provides GPs with funding, training and equipment to treat conditions, such as cellulitis, in the community.

A Waikanae resident recently benefited from this initiative by receiving intravenous antibiotics for a skin infection at

her GP clinic. Whereas previously she would have travelled to Wellington Regional Hospital for three days in a row to

receive treatment. The ability to be treated close to home is more convenient for

the patient and their caregiver. It also frees up valuable hospital resources to treat

other patients who have more complex conditions.

Primary options for acute care services are available in Hutt Valley,

Wairarapa and Capital & Coast regions for patients who meet

the eligibility criteria.

What patients can do:

• See your GP early - don’t wait for your condition to worsen as you could

unnecessarily end up in hospital• Call Healthline on 0800 611 116 for free

advice from a nurse to help you decide if you need to see a health professional• If you require treatment you’ve

previously received at hospital, ask your GP if there is an option for

this to be provided in the community.

optimum performance

Every year falls make up over half of the serious harm events reported by NZ hospitals. During the period

1 July 2014 to 30 June 2015 Capital & Coast DHB had 27 serious and sentinel events where patients

suffered harm while in hospital - seven of these events related to falls.

Our practice is to always communicate openly with patients and their whānau to acknowledge what has happened and to carry out a review to minimise the

risk of these situations recurring.

thousands more children are now

enrolled and accessing free dental care.

In July 2014, access to free dental health services for Porirua children aged 0-5 was low.

We matched data from local GPs with that of the Bee Healthy Regional Dental Service with the result that nearly 1800 more children are now enrolled and receiving dental

care. The matching exercise is being carried out in Kapiti, Hutt Valley and Wellington.

Babies born in the Wellington Region are now being enrolled with the Bee Healthy Regional Dental Service at birth, along

with a number of other key health services such as a GP practice.

With increased enrolment numbers more dental therapists have been

employed, including nine new graduates.

reduced health disparities

How you can help:

There are three easy ways to enrol your child with Bee Healthy Regional

Dental Service:1. Complete an online enrolment form at

www.beehealthy.org.nz2. Call 0800 TALK TEETH (0800 825 583)

and enrol over the phone3. Visit your nearest Bee Healthy Dental Clinic

and complete an enrolment formIf you have recently moved to the region, changed address and need to update your details, or can’t remember if your child is

enrolled, call 0800 TALK TEETH (0800 825 583).

Quicker and safer patient journeys that ensure faster access

to specialist treatment is the intention behind a new best practice principle called

right care, right now.We now aim for patients to be seen by specialists, such as a

cardiologist, in the emergency department, and decide what treatment needs to happen within 90 minutes.

The sooner a definitive decision can be made, the better the outcome for the patient and the sooner the next person waiting in

the emergency department can be seen.This faster access helps us improve our performance against the ‘Shorter Stays in Emergency Departments’ national health

target. The target is calculated from the time taken to treat and discharge patients in the emergency

department, and the time taken for a patient to be admitted to a hospital ward.

In 2013/14 we achieved 87% of patients being seen within 6 hours, in 2014/15

this had risen to 92% - closing in on the national target of 95%.

effective services

regional collaboration

How you can stay safe:

Here are a few tips to help keep yourself safe and prevent falls happening: • Be realistic about what you can do and

ask for help when you need it• Wear well fitting, flat shoes and slippers with

non-slip soles for increased stability• Don’t walk around in socks or stockings

• See a podiatrist or doctor if your feet are painful or swollen, or if you develop problems like bunions

• Keep active to maintain your strength and balance

• Make sure steps, stairs and walkways inside and outside are well lit

and clear.

How you can help:

• If you are unable to attend your hospital appointment please contact the outpatient booking office on 04 806 0992

as soon as possible to reschedule.• Write down any questions you have

about your illness or treatment and bring these to your appointment

• If you don’t understand what the healthcare worker is saying ask for more information or

for them to explain better • Ask questions

• Write down what you need to do next.

What is ‘right care,

right now?This is how we deliver care to patients in the

emergency department:Within 2 hours from the time you arrive at the

emergency department the team will decide if you need to been seen by a specialist.

Within 90 minutes from that decision being made the specialist will come to the emergency department

to assess you and confirm what treatment you require.

Within 1 hour of the assessment you will transferred to a hospital ward if you

need to be admitted.

Appendix 2.4.2


76

Appendix 2.4.3

1

Corrective Action Requests (CAR) Report

Provider Name: Capital and Coast District Health Board

Type of Audit: Certification audit

Date(s) of Audit Report: Start Date: 14 April 2015 End Date: 16April 2016

DAA: The DAA Group Limited

Lead Auditor: Catherine Cooney

Progress Report Due: 3 CARS - 3 months – Due 30/11/2015,

Std Criteria Rating Evidence Evidence

1.2.7 1.2.7.2 PA

Moderate

Finding:

The evidence available at audit shows:

- 61% of appraisals are current - 60% of health professionals have a current annual practising certificate - 60% of individual medical staff have completed their annual credentialling requrements

The organisation has not adopted service specific credentialling

The issue identified at the last audit related to the play therapist has still to be resolved, however work has been commenced in redefining the job description and providing guidance and supervision of these staff members from play specialists at Hutt Hospital.

Action:

a. Ensure annual practising certificates (APCs), credentialling and appraisals are current and up to date.

b. Complete the work plan related to the play therapist role

DHB Response

Annual practicing Certificates – We currently sit at aproximately 98%APC’s reported being current which is a signifcant improvement from the reported 60% in April 2015. Work is on-


77

Appendix 2.4.3

2

going to improve reliability of the electronic systems to accurately capture this information. In the interim whilst the reporting system issues are being resolved the professional heads together with the Operational Managers have a process in place to ensure all relevant staff have current practicing certificates.

Credentialing – As of the 30/10/2015 it is reported that 38% (159/430) SMO’s have been credentialed in the last 12 months. This is a priority for the CMO who is working towards 100% reported compliance by March 2016. This is monitored at the monthly Credentialing Committee, all SMO’s have been informed by memo, and this is a key performance Indicator for the Executive Clinical Directors of the Directorates. To assist this process the Quality Improvement & Patient Safety Directorate are working on Directorate/Service specific reporting by speciality to improve credentialing compliance visibility.

Performance Appraisals - As previoulsy advised CCDHB has established a process to electronically record performance appraisals. Managers had a deadline to complete the annual performance appraisals of staff by 26 September 2015. As of the 30/10/2015 44% (2555/5807) of staff were reported to have had their performance appraisal’s loaded into MYPal. Wiork is in progress to improve teh reliability of our electronic systemes to ensure accuracy of this data.

Play Therapists –The Hospital Certification Process during 2014 highlighted that some of the clinical assurance mechanisms for the play specialists were not in place e.g. recent apraisal, qualifications, membership of the Association etc. Some of these issues including appriasals have now been rectified. However others are more challenging to implement. Through this process of improving the clinical assurance mechanisms for the Play Specialists themselves, it has become apparent that a broader review of how the whole service operates to ensure that it is fit for purpose is needed so that CCDHB provides a high quality and safe play specialist service. It is therefore planned for the Play Specialist Leader at Counties Manukau to do a site visit before the end of the year and advise CCDHB on developement of the play specialist role and servcie provision.


78

Appendix 2.4.3

3

1.3.4 1.3.4.2 PA

Moderate

Finding:

- Goals are not identified in documentation on PADP documents across service areas at Wellington Hospital and in maternity services there is no specific place to record goals/desired outcomes on some templates in use.

- While some aspects of assessment are performed and recorded on the PADP and maternity documents at Wellington and Kenepuru Hospitals, not all elements of assessment are reliably completed including family violence screening for vulnerable adults. The admission checklist is not completed in many instances.

- Assessment does not reliably include family violence screening for vulnerable persons. - Admission checklists are not completed in many instances. - The PADP document is used to assess falls and other clinical risks. Overall these are

adequately completed where a care plan has been implemented. However, in MAPU, two patients in the unit for 44 hours and 11 hours respectively, do not have the document completed in the required timeframes in accordance with organisational requirements (eight hours and risk assessments within one hour of admission). Other file examples indicate that assessments are not always fully completed in the PADPs sighted.

Action:

Ensure patient goals are documented.

Ensure assessments consistently occur in a timely manner and the related documentation is completed.

DHB Response:

As previoulsy advised CCDHB moved to care process auditing and centralised collation of audit results to improve reporting, increase visibility and enable the Associate Directors of Nursing (ADON) and Midwifery (ADOM) to work with the ward areas on actions to address areas for improvement, with oversight of the Director for Nursing and Midwifery. This has resulted in a improvement in completion of patient goals and risk assessments in our adult and child inpatinet wards Please note for Maternity Services the ADOM is working with the Charge Midwife Managers regarding the Maternity Admission to Discharge planning documentation and improving audit compliance.

Criterion 1.3.4.2 CCDHB Falls Care process Audit results to Oct'15.doc

Criterion 1.3.4.2 Family Violence Screening Measures as at October 2015.doc

Criterion 1.3.4.2 PADP Compliance Audit results Oct'15.doc

Criterion 1.3.8.1 PI Compliance Audit results Aug '15 Nov'15.doc


79

Appendix 2.4.3

4

Patient goals - CCDHB overall compliance has increased from 16% in November 2014 to 50% in October 2015.

Risk assessments CCDHB overall compliance from November 2014 to latest audit:

Delirium Risk Assessment 64%to 85% (October)

Cognitive Risk Assessment 70% to 79% (October)

Family Violence Screening 50% to 51% (August) - The PADP is used in conjunction with the Patient Safety Assessment (green) form which was customised for Child Health and Women’s Health services. An electronic version of the screening tool has been developed for use in ED. Monthly reporting of FVID screening commenced in July 2015.

Infection Prvention & Control 80% to 85% (September)

Falls risk assessment 71% to 95% (October)

Pressure Injury Risk Assessment 25% to 47% (November)

NB: The audit tools do not audit that the risk assessments are completed within eight hours of admission, and the three key falls, pressure injury and infection prevention and control risk assessments completed within one hour of admission, as stated in the PADP policy. This is being addressed by the Nursing and Midwifery Leadership team.

1.3.8 1.3.8.3 PA

Moderate

Finding:

There is inadequate documentation of aspects of the care of the deteriorating patient:

- Sticker notation required on charts following a 777 emergency call or MET attendance are not consistently completed.

- Modified parameters on early warning scores (EWS, PEWS, MEOWS) are not reliably documented to make clear the expectations of the medical staff in regard to observations and activation of 777 calls as required by the policy.

- There is a lack of clarity of documentation for emergency events including retrospective notes.

- Documentation of action taken when the EWS are out of range. - Some care plans do not adequately provide for care of the patient at risk. - The PADP observations section did not match the timeframes of observations in a

Criteion 1.3.8.3 CAR EWS _PEWS Compliance Audit results Oct'15.doc


80

Appendix 2.4.3

5

number of cases. - There were observations that scored low on the EWS escalation criteria; however there

was no documentation of what action had been taken.

Staff knowledge and education in regard to EWS is inconsistent and not all staff have education recorded as completed.

- Family spoken to raised issues of not being listened to when they felt the patient was deteriorating.

- Nursing staff spoke of not putting out a 777 call prior to discussions with the medical staff of the area which is not the intent of the policy.

Action:

Ensure that:

a. Documentation for deterioration of the patient prevention and management is consistently managed according to policy.

b. Staff knowledge andducation in regard to managing the deteriorating patient (EWS) and emergencies is consistent with policy and is recorded.

DHB response:

Documentation for deterioration of the patient prevention and management is consistently managed according to policy.

CCDHB launched the revised early warning score (EWS) pathway and vital sign charts hospital wide in September 2015. All areas were updated regarding the importance of good documentation and the escalation pathway. The CCDHB audit schedule requires all wards to complete a EWS Compliance Audit every three months and the results are collated centrally. The key element checking that “Has the correct action triggered by the EWS been undertaken” from the audit results shows compliance at 96% for October. NB: A process to centralise the Maternity (MEWS) audit data is being established at present (PEWS collated). The hospital policy regarding Vital signs and EWS is being reviewed. The final draft has been completed and is being approved. Staff knowledge and education in regard to managing the deteriorating patient (EWS) and


81

Appendix 2.4.3

6

emergencies is consistent with policy and is recorded. Training packages were provided to the ward areas which included lanyards, teaching posters and general information on what resources were available to them. Training resources are also available via the ICU website which is dedicated to EWS across the DHB. A EWS eLearning tool is being developed that will form the basis for hospital-wide (medical & nursing) EWS training & (new) chart orientation. For Medical Staff - All ICU registrars (they attend every Medical Emergency Team (MET) call) receive orientation & support around their roles & responsibilities for MET. All new first year doctors (PGY1s) are taught about CCDHB’s Early Warning Score (EWS) as part of the ALERT course that they attend annually. They also receive education in managing deteriorating patients during this course. Junior doctors of all specialties are educated on aspects of acute care; this includes the importance of EWS, when invited by the intern supervisor For Nursing Staff – Training is undertaken by the individual wards. The PAR team and PAR Clinical Nurse Specialist (CNS) can provide additional support if requested. PAR link roles have been established where a PAR nurse will liaise closely with wards and provide any on-going support that is needed. Additional support - A dedicated email address ([email protected] ) is available to all staff to provide feedback and ask questions regarding the EWS. Emails are all responded to in a timely fashion by the Intensive Care Specialist or referred to Patient At Risk (PAR) Charge Nurse Manager or CNS to address any nursing issues. A newsletter is available to wards informing them of all the latest developments.


82

mailto:[email protected]


Page 1 of 7 05/02/2016

Memo

To: HAC,

From: Executive Director (Clinical) - Quality Improvement and Patient Safety Directorate

Executive Director (Operations) - Quality Improvement and Patient Safety Directorate

Date: 14 January 2016

Re: Monthly update of Clinical & Quality Measures

SUMMARY

Out of the 13 clinical and quality measures there is one measure that is showing variation outside the normal control at

CCDHB level related to restraint. We have established that the increase in reportable events was for 3 areas within

Mental Health Services– Te Aruhe, Te Whare Ra Uta and Haumietiketike. These were mainly related to a few

patients that required restraint due to their cognitive condition. All restraint events are required to be recorded

and are reviewed at the monthly Seclusion & Restraint Minimisation Group.

For the graphs please note red indicates where an indicator is showing an area of concern, amber indicates where an indicator is trending towards an area of concern, and green indicates where an indicator is within target range.

Definition: A count of the number of uses of Restraints or Supportive Devices reported in the Reportable Events system. Data source: DSU dashboard, Reportable Events, Reportable Events Monthly Report Commentary: refer the summary.


83


Page 2 of 7 05/02/2016

CLINICAL MEASURES – FOR INFORMATION – Normal Variability

Definition: The target is 95% of patients are admitted, discharged or transferred from ED within 6 hours. Data source: DSU dashboard, ED Measures

Definition: An average monthly number of occupied beds at 4pm each day including Wellington 1, 2 & Kenepuru locations. WLG1 = SSU, SAPU, MAPU, 4NG, 5NW, 5SW, 6NW, 6SW, 7NW, 7SW, SSR, ICU, WLG2 = DLV, 4NM, NCU, WRD1, WRD2, IRW, MHW, MHT Kene = WRD5, DTX, WRD6, WRD7, KSU, RaUTA, KMU, PMU. Data source: DSU dashboard, Corporate Reports, CPR Clinical Measures


84


Page 3 of 7 05/02/2016

Definition: A count of the number of uses of Safe Staffing incidents (harm to staff) reported in the Reportable Events system. Data source: DSU dashboard, Reportable Events, Reportable Events Monthly Report

Commentary: Nil.

Definition: A count of the number of all reported events captured Data source: DSU dashboard, Corporate Reports, CPR Clinical Measures

Commentary: Nil.


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Definition: A count of the number of deaths within the hospitals per month recorded in the DSU database. Data source: DSU dashboard, Corporate Reports, CPR Clinical Measures

Commentary: Nil

Definition: As CCDHB data was significantly different compared to the sub region the data set was reviewed and found that the data reflected changes in level of care (person already in Aged Residential Care (ARC) moves from Rest Home level care to hospital level or dementia care) as well as new entrants to ARC. This data set has now been refined to reflect only new entrants to ARC and the control chart updated from Jan 2013 accordingly to reflect this”. Data source: SIDU.

Commentary: Please note that this data will always be reported two months in arrears i.e. reporting on August figures in October.


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Definition: A count of the number of complaints received and recorded per week by the Quality & Risk team. Data source: DSU dashboard, Corporate Reports, CPR Clinical Measures

Commentary: Nil

Definition: A count of the number of SAC 1&2 events that have been reviewed and reported by the CCDHB Patient Safety Office per month. Data source: CCDHB Patient Safety Officer monthly report. Commentary: Nil


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Definition: A count of the number of all falls reported in the Reportable Events system. Data source: DSU dashboard, Reportable Events, Reportable Events Monthly Report Commentary: Nil

Definition: A count of the number of all Medication and Fluid reported in the Reportable Events system. Data source: DSU dashboard, Reportable Events, Reportable Events Monthly Report Commentary: Work is being done to appropriately categorise the medication/fluid reported events to enable targeted improvements to be put in place. There is special cause found this month & numbers of the reported events related to medication / fluid are lying outside the upper control limit.


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Definition: A count of the number of peri operative harm events according to the definition used by HQSC. Data is now available monthly within CCDHB. Data source: DSU dashboard that replicates HQSC definition. Commentary: Please note that this data will always be reported two months in arrears i.e. reporting on August figures in October. This is because the actual number of peri-operative harm/sepsis confirmed for the month is not available at the time that the report is written.

Definition: A count of the number of all Pressure Sores / Ulcers that were acquired onsite reported in the Reportable Events system. Data source: DSU dashboard, Reportable Events, Reportable Events Monthly Report Commentary: Nil


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CCDHB PaTIENT saFETY wEEkNovEmBEr 2015

Appendix 2.4.5


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