49

QUALITY ACCOUNT

1 July 2013 - 30 June 2014

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ContentsSection One - OPENING STATEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Foreword by Chief Executive Ron Dunham . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Statement of Endorsement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Statement of Engagement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Understanding the data contained in the Quality Account . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Section Two - PERFORMANCE REVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 National Health Targets - Our Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Serious Adverse Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Quality and Safety Markers (QSMs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Reducing Harm from Falls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Hand Hygiene . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Central Line Associates Bateriaemias (CLAB) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Surgical Site Infection Improvement Programme (SSII) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Reducing Perioperative Harm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Patient Experience Week . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Child Health Consumer Reference Group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 GP Deep Vein Thrombosis (DVT) Diagnostic Pathway . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Four Step Hearing Programme . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Improved Fluid Balance Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Venous Thromboembolism (VTE) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Medication Safety - Warfarin Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Safe and Standardised Clinical Handover (SBARR) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Heart Failure Clinic Pilot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Nurse-led Child Health Assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Free Dental Care for Lakes Pregnant Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Rheumatic Fever Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Lakes DHB and Rotorua Social Sector Trial Project - Excel Rotorua . . . . . . . . . . . . . . . . . . . . . . . . 42 Awhi Midwives and Awhi House Turangi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Section Three - FUTURE FOCUS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Action Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Statement of Intent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Welcome to the second Quality Account for Lakes District Health Board . It is a snapshot of current and planned activities to enhance health and patient safety .

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Section One - OPENING STATEMENTS

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Foreword

We are very pleased to present the second quality account, for the period 1 July 2013-30 June 2014 .Quality will always be key to the success of our staff, our organisation and our contracted health providers .Each year presents new challenges and opportunities in the quality arena .This year we held our first Patient Experience Week, during which we profiled a number of support staff and their contribution to the overall patient experience . We actively sought feedback from patients who had recently been in hospital, by way of morning teas during the week and received some very candid and thoughtful views on the patients’ experiences during their stay .Our Woman, Child and Family Service has successfully launched a child health consumer reference group, which is held bi-monthly and regularly provides useful and often unexpected suggestions as to how we can improve our services in this area .Our portfolio managers work with our community providers to develop services and initiatives that improve quality and safety for service users .As you read through the report you will see that we are continuing our journey of improvement across the six Quality and Safety Markers . One of these, hand hygiene has yielded very pleasing results .This document highlights a number of examples of quality initiatives which are helping to improve patient safety, clinical effectiveness and patient outcomes . Within the DHB hospitals, Safe and Standardised Clinical Handover has become embedded as “the way we do things at Lakes DHB” . In the community setting, the example of Awhi Midwives as a new model of maternal and child health integrated service provision is proving to be well accepted and popular in the Turangi community, with some very good clinical results .Our community pharmacists have been working on a new model of care that puts the service user at the centre . A new quality framework for pharmacy nationwide is being developed .We are working collaboratively across a number of agencies to continuously improve quality services for our population .I am confident this document provides a good representation of the passion and commitment of healthcare staff across the Lakes district, to make a difference for the health of our population .

Ron DunhamChief Executive

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Statement of Endorsement

Quality and the safety of hospital patients and staff, and health service users in our community are top priorities for the Lakes District Health Board .Provision of quality health services across the DHB is critical to the health of our population . A range of community providers (each with their own quality plan) measures and monitors service quality and effectiveness and submits monitoring reports to the DHB . A number of outstanding community-based initiatives are cited in this account, and are evidence that quality health care spans the whole community .The ongoing actions of staff are critical to patient safety, and as such our Board members take great interest in the host of quality improvement work that goes on in the organisation .

The Board has always shown great interest in the Health Targets and more recently the Quality Safety Markers overseen by the Health Quality and Safety Commission .All DHB staff, clinical leaders and managers are responsible for improving quality and participating in quality improvement projects and initiatives .Quality of care, listening to consumers and the community and preventing harm are at the centre of the Lakes DHB’s quality improvement plan . This work is directed from a clinical governance framework .The Board has been pleased to see a revamp of the Clinical Governance Group in the past year, and ongoing work to improve the quality of our services .

Deryck Shaw, MNZMBoard Chair

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Statement of Engagement

This document has been compiled, with contributions by various teams at Lakes DHB .There has been an attempt to provide improvement accounts across the sector linking in with our priorities of meeting Ministry of Health National Health Targets and Quality Safety Markers, reporting on Serious Adverse Events, Quality, Safety and Experience of Care and best value for public health system resources .The improvement work within Lakes DHB is based on “The Triple Aim” and the Plan-do-study-act (PDSA) cycle . The models are implemented by the use of the Institute for Health Improvement (IHI) methodology of improvement and therefore our publication contains explanations of the graphs so the reader can have context around the measures .

The Quality Account is designed as a complementary document to our Annual report and as such should be read in conjunction . This account aims to show our position nationally by reporting on the health targets and quality and safety markers and compares our results across the country, reports on the serious adverse events and the actions taken to minimise events reoccurring .We trust this document will give the reader confidence that the DHB is continuously improving the quality and safety of care and delivering healthcare appropriate for the needs of our community .

What are we trying to accomplish?

How will we know that a change is an improvement?

What changes can we make that will result in improvement?

Source: Adapted from IHI Quality Improvement Resources

Plan

Do

Study

Act

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Understanding the data contained in the Quality Account

During the 2013/2014 year an improvement advisor was trained through the Institute for Healthcare Improvement (IHI) Improvement Advisor Professional Development Programme . This was funded through a scholarship from the Health Quality and Safety Commission .It is hoped that in the future, the IHI methodology will become embedded in improvement activity at Lakes DHB .A key part of the methodology is the use of data for improvement purposes . Data for improvement are presented in a different way to that for research or accountability purposes . This approach allows for smaller samples to be collected more often in order to detect significant changes in the performance of a system, and respond to them appropriately . This avoids over reaction or under reaction to individual data points . The charts or graphs primarily used for improvement are called Shewhart Control Charts . There are several types of these with all of them having a centre line and control limits calculated in different ways depending on the type of data being measured . However, these control charts may all be interpreted in the same way .There are two types of variation seen in control charts:Common cause variation: The normal naturally occurring variation from day to day or week to week . For example the number of patients presenting to the Emergency Department (ED) will not be identical every day but will usually fall into a predictable range .Special cause variation: This is significant variation due to a new factor contributing to the normal system. (For example, a bus crash with 30 injured patients, or the increased volumes of people in the Lakes DHB region over Christmas, New Year’s and Easter would result in special cause numbers of ED presentations) . This is detected using standard rules for all control charts that identify particular data points or groups of data points as significant. For ease of use the following standard practice is adopted at Lakes DHB: l Special cause showing improvement is circled in green . l Special cause showing deterioration is circled in red . l Special cause with an unknown or neutral consequence is circled amber .

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Section Two - PERFORMANCE REVIEW

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National Health Targets - Our Results

Health Targets are a set of national performance measures specifically designed to improve the performance of health services . The targets are decided by the Ministry of Health and are reviewed annually to ensure they are in line with the government’s health priorities .

Below are the 2013/14 Lakes DHB Quarter Four results . Key A Achieved NA Not Achieved

National Health Targets

Health Targets are a set of national performance measures specifically designed to improve the performance of DHBs by focussing on rapid progress against key national priorities . They provide a focus for action .

Public reporting of DHB health target results is made every quarter comparing DHB’s performance and progress against the targets .

Below are the 2013/14 Lakes DHB Quarter Four results .

Key A Achieved - NA Not Achieved

Health Target Long Term Target

Lakes 2013/14

target Result Status

95 percent of patients will be admitted, discharged, or transferred from an Emergency Department (ED) within six hours .

95 percent 91 percent NA

Nationally, the volume of elective surgery will be increased by at least 4,000 discharges per year .

3659 total elective surgical

discharges

4166 total elective surgical

discharges

A

All patients ready-for-treatment, wait less than four weeks for radiotherapy or chemotherapy .

100 percent 100 percent A

90 percent of eight months olds will have their primary course of immunisation (six weeks, three months and five months immunisation events) on time by July 2014 .

Total 90 percent 89 percent NA

95 percent of hospitalised patients who smoke and are seen by a health practitioner in public hospitals and

90 percent of enrolled patients who smoke and are seen by a health practitioner in General Practice are offered brief advice and support to quit smoking .

Within the target a specialised identified group will include: Progress towards 90percent of pregnant women who identify as smokers at the time of confirmation of pregnancy in general practice or booking with Lead Maternity Carer are offered advice and support to quit .

Total 95 percent

Total 90 percent

99 percent

78 percent

A

NA

90 percent of the eligible population will have had their cardiovascular risk assessed in the last five years

Total 90 percent 88 percent NA

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Serious adverse events

Aim: To report to the community the serious adverse events that occurred within Lakes DHB health services during the 2013-14 year . At the same time, it is important to highlight the programmes we have developed as a direct result of serious adverse events and the subsequent investigations .

Benefits to Lakes DHB community:Reporting adverse events helps us manage the risks of providing healthcare. Incident management identifies problems and failures in the system so we can learn and prevent similar events from happening . This process should give the Lakes DHB community confidence that we are transparent and open about serious adverse events and equally, we are willing to learn from the mistakes .

What was involved?All health related incidents are “serious code” assessed . All code one and two events are publicly reported following in-depth investigations . Outcomes of the investigations can be shared across the DHB sector to enable widespread learning . Recommendations are monitored to ensure future risks are minimised .

Our Results: l Lakes DHB reported 12 serious adverse events over the 2013-14 year . l Three related to Mental Health & Addiction Services and were reported as self harm causing death . l Four of the events related to falls that caused serious harm . l The remaining five events were related to incorrect use of blood product, medication errors and/or issues with assessment, diagnosis, treatment and general care of a patient .

Due to the investigation recommendations, Lakes DHB made a range of improvements, including:

l A new and improved fluid balance chart. l Developed and maintained an ongoing reduction in falls programme . l Commenced a major medication safety project . l Improvements made for a safe and standardised clinical handover process across both hospitals .

Priorities for the next 12 months: l Audit and review the success of the fluid balance chart and continue to educate staff. l Reduce the number of falls with harm by carrying on with programme . l Work through the medication project and report on completed tasks in the 2014-15 year . l Complete the opioid related harm project and meet HQSC expectations . l Continue to educate and promote the handover model .

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This chart shows the time between individual serious adverse events . In general, an increase in time between events (i .e . fewer events) is desirable . However, a caution to consider is that an increase may also be explained by under reporting of events. We are fairly confident at Lakes DHB that we have a good reporting culture for serious adverse events . In this case there is no special cause detected in the incidence of serious adverse events over the last two years .

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Quality and Safety Markers (QSMs)

Lakes DHB is involved in reporting on measures to monitor the delivery and effectiveness of health care . One such measure is the quality and safety markers (QSMs), developed by the Health Quality & Safety Commission (HQSC) . This provides a measure on how we measure against other DHBs and where there is room for improvement .

The QSMs are: l Reducing Harm from Falls l Healthcare Associated Infections - Hand hygiene compliance . - Elimination of central line associated bacteremia (CLAB) . - Surgical site infection reporting and database (SSII) . l Reduction in perioperative harm .

The QSMs will help the HQSC evaluate the success of its campaigns and determine whether the desired changes in practice and reductions in harm and cost have occurred .

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Reducing Harm from Falls

Aim: To reduce the number of falls with harm . It is very common in hospital settings for patients to fall . Reasons include unfamiliar environment, illness, medications, infections and delirium . To have 90% or more of high risk patients assessed and an individualised falls care plan .

Benefits to Lakes DHB community: l A reduction of falls with harm in the community . l Patients go home and recover more quickly .

Our Results: l We developed a template to improve the quality of the root cause analysis process . l This year we have focussed on a process to educate staff on best practice for delirium management and prevention . l Accident Compensation Corporation (ACC) injury prevention coordinator at Rotorua Hospital . This is part of a multi agency initiative and pilot programme focussed on falls prevention and safer homes in a community setting . The initiative covered approximately 200 homes and included home safety assessments and advice relating to potential risks in the home . l The QSMs average scoring is in the 76-85% band for our two falls prevention process markers . This is below the 90% target . Lakes DHB reported four serious harm incidents from falls in the 2013-14 .

QSM results- How do we compare nationally?

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Priorities for the next 12 months: l Meet the QSMs set by the HQSC . l Further education and promotion by the unit falls prevention coordinators l An identification exercise of contextual issues that impact on compliance of completing risk assessment and an individualised care plan as required in the Quality Marker eLearning tool and National Health Service (NHS) Falls Prevention package working to establish if the NHS that Bay of Plenty DHB has been using for some time can be accessed by Lakes DHB staff . l Lakes DHB has put forward a proposal for the appointment of an Accident Compensation Corporation (ACC) / DHB joint funded gerontology nurse practitioner to work within community, primary and aged care sector with a focus on a range of initiatives aimed at reducing risk of falls . l Progressing with medication reconciliation for people over the age of 75 who are admitted at both hospital sites . l Initiating a credential programme for nurses to focus on risk assessment and high risk patients .

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Adapted from Southern District Health Board ‘A Guide to reducing your risk of falling while in hospital’ and NSW Falls Prevention Program ‘Falls prevention in hospital’.

� Keep important items within reach, including your call button or call bell.

� Take your time when you get up. Call us if you feel dizzy, weak, or light-headed - don't get up by yourself.

� Ask us for help getting to the bathroom or toilet, and use the bell there to ask for help if you don't feel well, or when you are ready to go back.

� Take extra care on wet or slippery floors.

� Watch out for any clutter or obstacles in your way, and ask us to move them.

� Use the handrails in the bathroom and hallway.

� Use only unmoving objects to help steady yourself. Don't use your IV pole, tray table, wheelchair, or other objects that can move.

� If you have glasses, hearing aids or walking aids, use them.

� Wear well-fitting shoes or non-skid slippers every time you get up. If you need assistance, ask for help to put them on.

� Make sure your clothing is not too long or too loose - it might trip you up.

� At night, turn on the light before you get out of bed, and turn on the light in the toilet.

If you fall while you are here, you could be injured and need to stay in hospital longer. Most falls happen when people are getting in or out of their bed, their bedside chair or going to the toilet.

* We want you to be as safe as possible while in our care.* We do not want you to fall and hurt yourself while you are here. * It's okay to ask for help if you need it.

We are here to heIp and we will work with you and your family/whanau/caregivers to keep you safe.

Doing these things will help to keep you from losing your balance or falling over.

Remember, it's okay to ask for help

if you feel unsteady or if there is anything

you are not sure about.

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This chart shows the number of occupied bed days between each fall with serious harm as defined by the national severity assessment code . In general, an increase in bed days between events (i .e . fewer events) is desirable . However, a caution to consider is that this may also be explained by under reporting of events . We are fairly confident at Lakes DHB that we have a good reporting culture for falls with serious harm. In this case there is no special cause detected in the incidence of falls with harm since 2009 .

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Hand Hygiene

What was involved?Hand hygiene was consistently reinforced over the past year at Lakes DHB as a crucial patient safety requirement . The infection prevention team is delighted to see that culture change is occurring and all areas are making steady improvement . Staff members were enthusiastic about preventing infection and harm to the patient through performing hand hygiene correctly at the correct ‘moments’ .

Our Results:One team, the Older Persons and Rehabilitation Service (OPRS) was identified as under performing against the national hand hygiene target . However, OPRS is now amongst the top teams at Rotorua Hospital . This has happened following a frontline ownership program . This involved staff making changes in the unit to make hand hygiene easier through better product placement and collegial awareness . They aimed to be the best team at Lakes DHB and they are close to reaching this target .

This year, results boards have been installed in each unit . Hand hygiene results were clearly advertised for patients, visitors and staff to view . We also launched a new set of hand hygiene posters on screensavers throughout Rotorua and Taupo hospitals to promote the benefits of good hand hygiene. We developed QR code mini posters as a different way of communicating with our patients and staff . Each area also has a hand hygiene champion .

This chart shows the hand hygiene compliance improvement at OPRS after successful frontline workshop .

020406080

100

Oct

-12

Mar

-13

Jun-

13

Oct

-13

Mar

-14

wee

k 1

wee

k 2

wee

k 3

wee

k 4

wee

k 5

wee

k 6

Com

plia

nce

perc

enta

ge

Date Audited

Hand Hygiene Compliance in OPRS

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Priorities for the next 12 months: l Focus on areas that are not consistently reaching the target . l Consolidating and improving compliance . l Investigating different ways to inform and educate patients and whanau about the benefits of hand hygiene . l Incorporate Taupo Hospital into the audit schedule . l To ensure there is an infection control representative in each unit or department .

QSM results- How do we compare nationally?

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Central line Associated Bateriaemias (CLAB)

Aim: Preventing infection in the high risk population and to reduce the rate of CLAB in New Zealand ICUs towards zero (<1 per 1000 line days)

BackgroundThe use of catheters to deliver treatment into a patient’s blood stream and monitor their progress is common practice . However the process creates a potential entry point for infection . Of particular concern are blood stream infections caused by central line catheters which are inserted into the blood vessels near the heart . Such infections are known as central line associated bacteremia (CLAB) and their prevention is vital in the fight against healthcare associated infections .CLAB is preventable . There is international evidence for best practice . The average cost of each CLAB incident is between $20,000 and $54,000 per patient . The mortality rate from CLAB is estimated to be 10-50% .

What was involved?Using the insertion and maintenance bundle to prevent CLAB .

Insertion bundle percentage compliance rateThis is a measure of how well the teams are adhering to the bundle of care (formatted into the insertion checklist) . Although the checklist itemises the individual components of the bundle, the measure is whether the entire bundle has been implemented each time-an “all or nothing” indicator . If even one element is missing, then the case is not in compliance with the bundle .

Maintenance bundle percentage rateThis is a smaller measure to the insertion checklist compliance, but in this case it is compliance with the maintenance checklist for each shift . Any shift that is not compliant with all the elements of the maintenance bundle means that overall maintenance compliance for that day is not achieved .

Our ResultsWe had an increase in our compliance with the CLAB bundle . However, one CLAB infection occurred this year compared to no CLAB infections last year .

Priorities for the next 12 months l To increase QSM results to 100% . l To prevent CLAB .

QSM results - How do we compare nationally?

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Surgical Site Infection Improvement Programme (SSII)

Aim: To prevent infections occurring in any hip or knee joint replacement undertaken at Rotorua Hospital .

BackgroundSurgical site infections represent a significant proportion of hospital acquired infections. The impact on morbidity, mortality and cost of care has resulting surgical site infection reduction being identified as a top national priority for the New Zealand health and disability sector .

Until 2013 there was not a nationally coordinated programme within New Zealand health and disability sector . However significant work has been done over the past year, and there is now a coordinated approach .

The SSII programme was started at Lakes DHB in July 2013, and involved:

l Implementation of evidence based guidelines . l Data collection . l Accurate outcome measurements . l Involving clinical teams .

QSM results - How do we compare nationally?

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Reducing Perioperative Harm

Aim: To prevent harm to any patient undergoing surgery by using the triple approach of briefing, check list and debriefing.

Benefits to Lakes DHB community:Patients do not succumb to any unnecessary harm and that all elements of the surgery are well planned and not include any delays . Patients go home earlier and recover from the hospital admission more quickly .

What is involved?To meet the QSM a retrospective audit is undertaken to ensure that the checklist has been completed prior to the commencement of all surgery .

Our Results:Lakes DHB has meet the 100% target for this marker on each occasion data has been submitted . Lakes DHB has also been involved in a’ proof of concept’ site to introduce the triple aim: approach, briefing, checklist and de briefing. This programme has been introduced into one theatre.

Priorities for the next 12 months: l Introduce the triple aim project to all theatres at Lakes DHB l Participate in a video on preventing perioperative harm with the HQSC l Maintain the 100% target for the QSM

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Patient Experience Week

Benefits to Lakes DHB community: l Give consumers the opportunities to feedback on positive experiences and explain any difficulties and areas for improvement . l Ensure patients and their whanau had an opportunity to tell their stories and staff members are able to identify improvement opportunities .

What was involved?To kick off the week, we decided to focus on support staff members that normally don’t have much of a profile in terms of their contribution to the overall patient experience .

We selected seven staff – the woman who cleans the Emergency Department as a worker for the contracted cleaning company; a food ambassador who interacts with patients around their meal requests and delivers the food; a heath care assistant; a chaplaincy team volunteer; the main hospital receptionist; a ward receptionist/clerk; and an attendant .

We profiled each about their role and their views on interacting with patients and provided context by stating how many of each of these employees we have .

At the launch of the week a senior physician who is also the clinical director for quality and innovation spoke about the week, the support staff stars and how we hoped to talk to previous patients over the week about their experiences, and we provided a morning tea and a wee gift for the profiled support staff, along with a box of chocolates to share among their team mates .

“The staff at Rotorua were excellent all helpful

and responsive”

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Our Results:Each of the remaining four days of the week were allocated to different services, the recent patients of that service ‘targeted’ and invited to come in and share their views on their experience with our staff . While we did not have a huge number of patients come in, we did have some very willing people who were very happy to share their candid yet thoughtful views about their experiences as a patient . On the Monday launch day, line managers and colleagues of the support staff being profiled attended, along with staff interested in hearing what was going on . This was not a huge event, but a great start and a nice way to start the week . This was promoted via our staff intranet, with posters about the week, and wrap up coverage in our staff newsletter. Each of the support staff profiled also received a copy of their individual profile.

Priorities for the next 12 months: l There are many staff who work in support roles but who contribute to the patient experience . We want to include a different group in the future, and build on the numbers of patients coming in to provide their feedback . l To repeat the process by inviting a larger group of patients to join us . l Extend the gathering of consumer feedback through the QSMs on consumer experience . l To co opt one or two consumer representatives onto the Clinical Governance group and Infection Control Committee . l Engaging a family in complaint management .

“Hunga Maanaki is very good”

“When she is well would like to talk with her

hapu about her experience and give health messages about taking care

of themselves.”

“Surgical nurses and staff are very caring.”

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Child Health Consumer Reference Group

Aim: Improve the partnership with young people and families using child health consumer reference group .

Background: l Woman, Child and Family Service at Lakes DHB was actively seeking consumer feedback through a new child health consumer reference group since late in 2013 . The group is run in partnership with Tipu Ora, and the meetings are held at Tipu Ora premises, away from the hospital . l The initiative is driven by the need to improve our partnership with users, their families and our community, and the need to ensure new facilities are designed in partnership with the users and their families .

Benefits to Lakes DHB community:This initiative has given our community the opportunity to influence the design of service delivery elements to better meet their needs . It also improves integration across all the child health services within Lakes DHB – all are invited to attend .

Our Results: l Bi-monthly meetings held since October 2013 . l Significant feedback received resulting in some changes to service delivery processes and the development of some new services and processes . l Some feedback related to how difficult it was for parents of disabled children to physically get into Rotorua Hospital; especially with younger children . This feedback helped underline the need for volunteers to assist those people coming into the hospital who need help and to provide a more welcoming presence . l A volunteer service has been initiated to assist these groups and others coming to Rotorua Hospital l Two participants talked about their experiences with ACC and education agencies which highlighted the need for an advocacy service for parents trying to manage their child’s care across all the agencies involved .

Priorities for the next 12 months: l Continue with communication and partnership activities and encourage more staff to attend the meetings .

“It’s the basic things such as introducing

ourselves when we go into a room, and of not

underestimating the ability of parents and family members to understand the medical plan.

Service ManagerWoman, Child and

Family

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GP Deep Vein Thrombosis (DVT) Diagnostic Pathway

Aim: To keep the diagnosis and treatment of deep vein thrombosis (DVT) in the community and reduce the number of referrals through the Emergency Department (ED) for DVT to allow clinical care in the community .

Benefits to Lakes DHB community: l Improved diagnostic process which allows treatment to commence without delay . l Treatment can be performed by GP reducing requirement for patient to attend ED or to be admitted to hospital .

Our Results:Overall there has been an increase in the number of referrals for ultrasound examinations for lower limb deep vein thrombosis .Since the inception of the pathway there has been a reduction in the number of referrals through ED despite the increase overall in referrals .

Background:The Lakes DHB diagnostic and treatment pathway was an initiative to share care across primary and secondary services by way of the Map of Medicine . The overall aim is to be able to diagnose DVT in a timely manner and be able to treat the patient within the community and therefore avoid unnecessary presentations to ED . Radiology, as the provider of the ultrasound service was a participant in the pathway development .The pathway was implemented in February 2013 as a result of shared discussions between GPs, DHB clinicians and radiology . Initially the implementation experienced some issues around process as teams worked through the newly developed referral pathway . The GP liaison role was vital in working through these issues as was the lead pathway project manager .

Priority for the next 12 months l To complete an audit of the number of positive findings versus the number of referrals. l To use the audit information for education and future planning .

27

Four Step Hearing Programme

Aim: To support hearing impaired patients and staff to communicate more effectively . We want to ensure that the patient has received information about their condition and treatment options prior to giving any informed consent .

Benefits to Lakes DHB community: l Hearing impaired patients and their family feel supported and gain confidence that the individual receives the information required .to understand their health condition and treatments offered . l Hearing impaired patients who are unable to/do not have access to their personal devices will have access to Bellman devices during their admission to support communication with their health care team . l Staff will be able to identify hearing impaired patients more readily and communicate more effectively .

Our Results: l The Bellman devices have been issued to the Clinical Equipment Pool at Rotorua hospital . Lakes DHB is grateful to the Rotorua Trust for funding the devices . l Bellman devices are now accessible 24 hours a day . l Customer alert signs to advise patients and families these aids are available have been placed in all areas of the hospital . l Hearing loss bed signs and magnetic alerting buttons are available for use in clinical areas . l Feedback from users and families has identified that the Bellman devices have helped communication considerably .

Background: l Tauranga Hearing Association offered Lakes DHB access and support to implement this four step hearing initiative . l An audit was undertaken in all clinical areas to estimate what signage and equipment was required across the hospital . l Discussion with Lakes DHB audiometrist identified that there was an increasing need for portable hearing devices in the hospital . A number of devices were managed from the Audiology Department during work hours but it was identified that the need was often outside these times and the process to manage delivery, cleaning and maintenance of the devices was not formalised and posed problems .

Priorities for the next 12 months: l Gather patient and family stories in relation to the success of the Bellman devices in order to assist with future funding requests and marketing initiatives . l Monitor use of the hearing impaired stickers on the front of clinical files. l Audit use of the Bellman devices . l Introduce the programme at Taupo Hospital .

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Improved Fluid Balance Chart

Aim: To develop an improved fluid balance chart that supports both simple and complex fluid management providing accurate documentation improving safety for patients.

Background: In November 2011 Lakes DHB received a complaint via the Health and Disability Commission (HDC) which highlighted serious issues regarding fluid balance documentation at Lakes DHB.

The HDC requested that Lakes DHB review processes for documenting accurate fluid balance. The subsequent review found both medical and nursing staff practices to be sub-optimal .

Using the IHI framework the steering group developed an improved fluid balance chart which was released this year .

Benefits to Lakes DHB community: l The completed form has the ability to capture the patient’s fluid status every shift as well as every 24 hours . This improves the management and monitoring of fluid and electrolytes, improving safety and quality of care for our patients . l An improved fluid management regime reduces complications and possible stay in hospital, leading to a quicker recovery .

Our Results: l A new and improved fluid balance chart has been introduced to all inpatient areas at Rotorua and Taupo hospitals .

Priorities for the next 12 months: l Regular auditing with results on patient safety boards . l Promote this patient safety programme within the Midland region with a presentation at the regional Patient Safety workshop . l Promote the chart nationally .

29

Venous Thromboembolism (VTE)

Aim: That Lakes DHB achieves 100% compliance for risk assessment on all patients admitted over 16 years old or pregnant teenagers on admission or change of condition and prescribe evidence- based thromboprophylaxis . This is a blood thinning medication that reduces the risk of clots forming (VTE) .

Background: There was a lack of current, evidence-based VTE prevention guidelines, lack of risk assessment tools and variable practice of personal preference - jeopardising patient safety .

Benefits to Lakes DHB community:Reduction in avoidable death and disability from hospital-acquired events

Our results: l Increased awareness amongst Lakes DHB staff members and patients l Assessment forms easily visible and accessible l Laminated cards in patient folders (as a reminder) l Education for doctors, nurses, midwives and patients l Regular “Plan, Do, Study, Act” PDSA cycles and feedback to clinicians l Introduction of VTE Prevention Nurse educator and auditor

Summary l Hospital-associated VTE is the most preventable cause of hospital related mortality and morbidity l VTE prevention programme started in July 2011 l VTE prevention nurse appointed July 2012 l Small hospital 136 (measurable) beds, 179 total l Average 12 events per year, three deaths

30

l Numbers reduced by half in last two years, three Gastro Intestinal bleeds reported, responding to transfusing and Proton pump inhibitors l Medical Unit best improvement l Orthopaedics events mainly lower limb trauma/surgery l Cost savings - $40k per year - removing foot pumps/thigh high Thrombo-Embolic Deterrent (TED) stockings .

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Medication Safety - Warfarin Chart

Aim: To ensure safe prescribing and administration of warfarin at Lakes DHB .

Background:The medication safety group has a priority to target high risk medicines . l Previous warfarin chart had limited guidelines, space and instructions for initiating, prescribing and administrating warfarin . l Warfarin is a high risk medicine and the management of it has been identified as high risk for errors therefore developing a workable chart with clear guidelines would increase patient safety .

Benefits to Lakes DHB community: l A risk assessment to ensure that it is a safe medication for a patient . l Patient receives the correct dose at the correct time . l Patients are safe in the knowledge that Lakes DHB clinical staff has access to clinical guidelines .

Our Results: l General information about initiating warfarin when clinically required . l New user friendly chart developed includes guidelines for prescribing . l Space for recording the target International Normalised Ratio (INR) levels . l Chart has more space for prescribing and recording administration . l To ensure safety the chart contains pictures of the medication and their doses . l Discharge checklist to ensure patient goes home with all necessary information

Priorities for next 12 months: l To audit the effectiveness and correct use of the chart . l The next project for the medication safety group is opioid related harm and the process is getting started to work on this .

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Safe and Standardised Clinical Handover (SBARR)

Aim: To agree on a specific model of handover that is consistent throughout the organisation. The handover process needed to be flexible enough to enable every handover to be safe for patients and staff .

Benefits to Lakes DHB community:Handover of care has been described as one of the most perilous procedures in medicine (Lilleyman, 2004) . Lakes DHB wants to ensure that every patient has the correct assessment diagnosis, treatment and care .

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What was involved? l A literature search was undertaken . The recommendations were that the organisation used the OSSIE guidelines as a framework . l This was then developed so the model accepted was Situation Background Assessment Recommendation Response (SBARR) . l Education and marketing were undertaken, using staff meetings and staff handovers to introduce the model. Posters, forms, pads and pens, all with specific prompts for staff to make the introduction of the model easy .

Our Results: l Many staff have adopted the model and are insisting when receiving a call or transferring a patient that the model is used . l There is a wide expectation that the model will be used when ringing for clinical advice . l If the hand over is written then this is included in the clinical file. l The reverse side of the form is continuation paper so that the handover notes become part of the contemporaneous notes .

Priorities for the next 12 months: l To ensure that the model is used for all verbal handovers throughout the organisation . l To introduce the SBARR into written clinical documentation .

34

Heart Failure Clinic Pilot

Aim: To promote patient self management through education and better support of patients with congestive heart failure .

Background:Research has shown that readmissions to hospital and ED attendances can be reduced with a heart failure clinical nurse specialist working collaboratively with a physician/cardiologist, following up patients with congestive heart failure (CHF) . The admission rates for heart failure are climbing with an ageing population as identified by the following graph.

What was involved?A fortnightly combined clinical nurse specialist (CNS) and physicians congestive heart failure clinic was set up as a pilot to follow up selected CHF patients following discharge from hospital . The primary foci of the clinic and this pilot included: l Increase research-proven heart failure medications given . l Manage fluid intake and retention. l Promote patient self management through education and better support . l To support the business case for a designated heart failure CNS position .

Our Results: l Once reviewed in clinic no patients were readmitted to hospital with heart failure from the clinic population . Given that some of these patients had had multiple readmissions in the months prior and were very high risk for readmission this is a very good outcome . l One patient, who was on the waiting list for a heart transplant, had six admissions over four months prior to the commencement of the trial . He had one admission at the very beginning of our trial then no further admissions as he was regularly followed up in our clinic . He subsequently went on to receive a heart transplant four months into our trial period . It is very likely he would have had many more admissions to hospital prior to receiving his transplant, and may very well not have made it to

Heart Failure Admissions by Fiscal Year Excludes 2014

137

171165

200

100

120

140

160

180

200

220

2010 2011 2012 2013

Total

35

transplant . l It would appear from the data over the six month period July to December 2013 there has been one of the lowest readmission rates for patients re-presenting within 28 days with their heart failure and all cause re-admission . It is disappointing that two patients who were readmitted were on the wait list to be seen in clinic . l A high degree of satisfaction voiced from patients regularly attending clinic – two patients sent letters of appreciation to Lakes DHB in support of the clinic .

“I don’t think Icould evermanageon my own”

Better facilitatetransitionary care

Setindividualisedcaremanagementplans

Recognise support structures

Deliverpatient-specific healtheducation

“They say you gota heart failure soyou got heartfailure”

“I do exactlywhat they say”

Strictadherence butlimited healthliteracy

Heartfailurenursespecialistrole

Adopt acollaborativemultidisciplinaryapproach

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Nurse-led Child Health Assessments

At Stand, Rotorua Children’s Camp

Aim: To discover any health issues that are impacting on the children attending Stand, Rotorua Children’s Camp and enable resolution, or referral to achieve resolution, of them .

What was involved? l Completion of health checks on the children attending Stand for whom parental consent had been obtained . l Referral as required to appropriate health agencies both local and in the child’s home area . l Provision of health information to the child, the parents/caregivers and to Stand staff ensured better planning for the child’s stay at Stand and later at home .

Benefits to Lakes DHB community: l A relationship has been developed with the staff of Stand so they feel comfortable discussing any health concerns that they have noted . l Education sessions with the staff have taken place regarding treatment regimes and protocols for encopresis and enuresis . l Often the children have not had a recent health examination with a health professional for various reasons such as transport, isolation from health facilities, also financial restraints. l Examinations include a basic hearing and vision test, teeth check and general health check . Time was also spent with the children to see if they have any concerns . l It is an ideal environment for teaching the children to manage this condition from a practical and medical approach – stable environment .

Our Results: l As a result of some of these examinations there have been referrals to oral health services, optometrists, ear nurse specialists . Any resulting disclosure is also discussed with staff and addressed appropriately . l Together with the staff a regime for management of encopresis (bed wetting) has also been developed as this condition is over represented in the medical conditions of some of the children attending Stand . l Working alongside the management at Stand a consent form was developed for the parental consent . As part of the project the clinic was stocked appropriately and Standing orders have been developed for the treatment of basic health concerns . l Templates for the reporting purposes copies of these go into the children’s files and also a copy to the parents . l Since commencing the project there have been three intakes of children, these intakes are for periods of five weeks. l A total of 63 children had assessments completed .

Background:The daily focus of Stand work is to protect children from further trauma, support their recovery and enhance their wellbeing . Stand is a charitable organisation that includes a children’s village located in Rotorua and funded predominantly by the Ministry of Social Development. Stand provides a five or six week live-in experience for children aged

37

five to 14 from anywhere in the top half of the North Island. Lakes DHB has partnered with Stand to offer a comprehensive nurse-led health assessment as part of the services offered . Early detection of existing unresolved health concerns enables better planning for the child’s stay and can be instrumental in resolving some conditions . The health assessment and recommendations to the parents and to Stand also helps prevention of other conditions .Priorities for the next 12 months:Continue with health assessments with appropriate referrals to health agencies with improved health literacy for the children and their families in the community .

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Free Dental Care for Lakes Pregnant Women

Aim: To provide access to free basic dental care in pregnancy . To ensure pregnant women have the opportunity to be dentally fit in pregnancy and pass on good oral health information, education and habits to their children .

Background:In the 2013 calendar year there were 1430 live births to Lakes DHB domiciled women . Of these births 51% of the babies were discharged to live in areas of deprivation 9 and 10 and 55% were Maori. It is identified form the Lakes DHB ASH Report and Lakes DHB oral health statistics that these children as pre-schoolers and five year olds suffer significantly poorer oral health when compared nationally and with their non-Maori peers. They have higher rates of dental caries at age five and higher rates of decayed, missing and filled teeth. In addition they are over represented in hospital discharge data for 0-4 year olds being admitted to Lakes DHB hospitals for dental work . There are several initiatives the DHB is implementing to address this health need . The access to free dental care for pregnant women was implemented as a strategy to improve the oral health of mothers and pass good habits onto their future children .The service aims to ensure that there is free access for women to basic dental care in pregnancy . This is in response to the high proportion of women giving birth with unmet basic oral health care and the evidence supporting maternal oral health has a lifelong effect on the general health of the babies across their lifespan .This will ensure pregnant women have the opportunity to be dentally fit in pregnancy and pass on good oral health information, education and habits to their children .

Benefits to Lakes DHB community: l Free oral health care in pregnancy contributes to positive oral health, reducing inequalities in oral health both for the pregnant women and their children . l The service ensures pregnant women have information on how to enrol their child in the community oral health service by 12 months of age . It also provides tooth brushing packs for the family .

Our Results: l This service has been running for the past 12 months. It has highlighted a significant need in the women who meet the threshold for this service . We have three providers; Tipu Ora, Clinical Horizons and Turangi Dental . l All pregnant women referred have required work ranging from extensive cleaning to full removal of teeth and dentures made and provided . Most of the work required is extensive and has surprised the dentists and referrers . Priorities for the next 12 months: l Lakes DHB’s Planning and Funding division will continue to evaluate the service and the level of need . This information will be used to inform the on-going funding of the service, and reporting regionally and nationally to other DHBs . To date there are only two DHBs providing this community service . l We will need to address the pathway to keeping these women engaged in oral health care after pregnancy and the pathway for these pregnant women to remember to implement access to oral health enrolment for their babies at age 12 months . 1 Smith, B . (2012) . Lakes DHB ASH Update report to Executive . 2 Ministry of Health . 2014 . Indicators for the Well Child / Tamariki Ora Quality Improvement Framework March 2014 . Wellington: Ministry of Health .

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Rheumatic Fever Prevention

Aim: The overarching goal for Lakes DHB is to reduce the incidence of rheumatic fever amongst the total population (primarily Māori and Pacific peoples) by two thirds by 2017. In order to achieve this, there are three critical objectives for Lakes DHB;

1 . Early prevention: Broad social, economic and environmental initiatives undertaken to prevent or limit the impact of Group A Streptococcus (GAS) infection in a population . Lakes DHB to undertake interventions Aimed at preventing the transmission of Group A streptococcal throat infections .

2 . Primary prevention: Reducing GAS transmission, acquisition, colonisation and carriage or treating GAS infection effectively to prevent the development of Acute Rheumatic Fever (ARF) in individuals . Lakes DHB interventions will be Aimed at community and primary health care level through; appropriate detection and management of GAS pharyngitis, further development of free and accessible diagnosis and treatment for children and young people . Primary prevention also includes community awareness raising initiatives and continuing professional development for health professionals .

3 . Secondary prevention: Accurately administering regular prophylactic antibiotics to individuals who have had an episode of ARF to prevent recurrence and the further development of Rheumatic Heart Disease (RHD) or to individuals who have established RHD to prevent recurrence and the progression of the disease . Lakes DHB, secondary prevention is closely linked to the implementation of a regional register, with monitoring and auditing capabilities . Care pathways and bicillin prophylaxis protocols are also aimed at preventing further recurrence of ARF and RHD .

4 . Tertiary prevention: Intervention in individuals with RHD to reduce symptoms, recurrence and disability and prevent premature death . Lakes DHB acknowledges the need to ensure excellent clinical follow up of patients with an existing diagnosis of ARF and RHD .

Background:ARF has been clearly recognised as a significant problem in New Zealand which needs to be addressed. Lakes DHB recognised ARF as a priority issue in 2008 . In 2009 a joint steering group was established to lead a range of DHB funded initiatives to address rheumatic fever which are now at various stages of implementation . Ministry of Health funded projects were introduced in 2012 .

The approach taken so far has been based firmly on the Heart Foundation rheumatic fever guidelines, taking into account the local epidemiology and community input .

Actions have been implemented in the following areas: l Raising public awareness that ‘sore throats matter’ . l Continuing professional development for health professionals . l School based throat swabbing campaigns . l Improving notification of ARF cases. l Improving case management, including progress on a combined rheumatic fever register across Lakes DHB . l Enhanced surveillance and audit of cases .

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A range of positive results has been demonstrated . These include raised awareness of rheumatic fever in higher risk communities and the general public; increased awareness of the sore throat guidelines among primary health care; the refining of the Lakes DHB rheumatic fever register, improved notification, and school based throat swabbing programmes that are operating to agreed protocols that have the support of local communities .

Benefits to Lakes DHB community:The purpose of the rheumatic fever prevention work is to enable Lakes DHB and its partner organisations to co-ordinate services and prioritise initiatives to achieve the government’s better public service target to reduce the incidence of rheumatic fever by two thirds to 1 .3 cases per 100,000 people by 2017 . The project also aims to minimise the impact of rheumatic fever and rheumatic heart disease (RHD) in the population served by Lakes DHBRheumatic fever is a preventable cause of serious illness and death in the Lakes District Health Board (DHB) population, almost exclusively affecting our Maori children . It has been virtually eradicated in most developed nations, but not in Lakes DHB . Of serious concern in Lakes DHB, we have seen a steady increase in acute rheumatic fever (ARF) notifications between 2001 and 2012.This particularly debilitating illness, from a seemingly minor throat infection in childhood or adolescence can lead to serious heart valve damage and a lifetime of medical treatment . Yet the illness is almost 100% preventable. The overarching benefits to the Lakes population are a reduction in the numbers of children with a diagnosis of ARF .Since 2009 efforts to address rheumatic fever have been led by the steering group . A multifaceted approach was adopted with the revision of priorities from year to year, with a focus on primary, secondary and to a lesser extent tertiary prevention . With the adoption of a challenging national target for the reduction of rheumatic fever rates and confirmation that health is to take the lead across sectors, primordial prevention will be a new and significant area of work. The steering group agreed broad priorities for action across both Lakes and Bay of Plenty DHBs from 2013-2017, including: l Addressing the determinants of health, in particular housing and overcrowding l Establishment of a rheumatic fever register across BOP and Lakes l Community awareness rising l Continuing professional development for health professionals l Easier access to primary care l Ensuring the delivery of high quality school based programmes to ensure that children have access to prompt treatment, to ensure that services are operating safely and to contribute to national evaluations of effectiveness l Meaningful monitoring – process and outcome evaluation

Our Results: In the 18 months since work commenced a multi pronged approach has seen a Lakes DHB five year plan developed and the following achievements to date:

l Early Prevention: implemented referral pathways and follow ups, for patients at risk, to improved housing including home insulation programmes and priority for state housing . In addition promotion and support to housing initiatives across the DHB .

l Primary Prevention: the implementation of access to rapid response clinics across the community and schools to enable free and rapid diagnosis and treatment for Group A Streptococcus . This includes nurse led clinics, school and youth health clinics and monitoring for improved compliance with oral antibiotics .

41

l Secondary Prevention: All ARF patients are provided with a robust care pathway from secondary care discharge into primary and community care and on-going follow up . This includes their routine bicillin administration and improving compliance within the best practice timeliness . The patients are tracked on a rheumatic fever register for their on-going care and follow up .

l Tertiary Prevention: this maintains the tracking of all ARF patients through their lifetime to ensure correct follow up and on-going treatment .

To date Lakes DHB has met the Ministry and Prime Minister’s Better Public Health Service target in preventing the increase in ARF cases and the beginning of a downward trend .

Priorities for the next 12 months:The Lakes DHB Rheumatic Fever Plan is a five year plan from 2012-2017. The priorities for the next 12 months include raising the profile of rheumatic fever and increasing the child health nursing in the community areas of the highest incidence . This will include increasing access to rapid response clinics both in primary care and the high needs populations .The Ministry of Health has set Lakes DHB a 2014-15 target of a further reduction in the number of rheumatic fever cases of 40% less than the 2011-12 baselines .There is a strong link between housing conditions, particularly household crowding, and rheumatic fever . Living in crowded housing conditions increases the transmission rates of a range of infectious diseases including Group A Streptococcal (GAS) throat infections, the necessary precursor to rheumatic fever . This is in relation to both the size of the house compared to the number of people living in it (structural crowding), and ensuring not too many people crowd into a single room to sleep, due to an inability to provide a warm, dry house (functional crowding) . The Lakes DHB 2014-15 Annual Plan requires the development and implementation of robust systems to identify families with children at high risk of rheumatic fever living in crowded housing, and appropriately refer each case to local housing and/or social services for follow up and intervention .The overall objective is to reduce household crowding in families with children at risk of rheumatic fever, by designing and implementing a healthy homes service in the DHB population .

RF020 | Sept 2013

Rheumatic fever

Rheumatic feverand hearts

ENGLISH

fefef vevev r

Steps of rheumatic fever

Sore throat

Sore throat checked Sore throats not checked

Go to doctor or nursestraight away to get everysore throat checked.

o get every

hard to swallow trouble eating or drinking

Sore throat is ‘strep throat’(caused by bacterialinfection or bug calledGroup A Streptococcus).

‘Strep throat’ is treated -take antibiotics for 10 days.It’s important to finish allthe antibiotics.

Stops ‘strep throat’ andrheumatic fever.

Don’t go to the doctor ornurse to get sore throatchecked, stay unwell.

Sore throat could be ‘strep throat’.

‘Strep throat’ not treated with medicine(antibiotics).

Rheumatic fever could develop.

Get very sick from rheumatic fever- tiredness, sore and swollen joints(knees, elbows, ankles and wrists).

If your child gets rheumatic fever,it may cause permanent damageto their heart valves. This is calledrheumatic heart disease.

A heart valve acts like a one-way door. It makes sure that blood pumped by the heart flows inone direction only. When the heart valve is damaged it can leak and may:

make it hard to breathe

make your child feel tired all the time.

How does myheart work?Your heart is located under theribcage in the centre of your chest

between your right and left lungs.

Its muscular walls beat, or contract, continuously. This pumps blood toall parts of your body.

A normal, healthy adult

heart is generally the

size of a clenched

adult fist. However,

some diseases of

the heart can cause

it to become larger.

Your heart The heart muscle is special as it pumps blood

around your body. The blood provides your body

with oxygen and nutrients. If something is

wrong with your heart it can affect other parts of

your body. This is why it’s important to look

after your heart.

42

Lakes DHB and Rotorua Social Sector

Trial Project - Excel Rotorua

Aim: Ensure all five and six year old children in Rotorua schools have had their hearing and vision screened as part of the B4 school check . For those who missed their hearing and vision screening, offer the screen at school in 2014 .

Benefits to Lakes DHB community: l All children aged five and six in Rotorua schools who did not have their hearing and vision screened at four years of age will have a screen completed at school in 2014 . l Referrals will be made to specialists as required .

Our Results: l Children needing screening have been identified in each school. l The number of children who missed their four year old hearing and vision screen is minimal (120 in total – five and six year olds). l Screening programme has commenced for those children requiring screening . l Data matching issues between the Enrol and B4 schools database have been identified and escalated to the Ministry of Education for resolution .

Background:This project supports Excel Rotorua Social Sector Trial . The trial aim is to remove sight and hearing as a barrier to children in Rotorua being able to learn .Excel Rotorua approached Lakes DHB to support them with a hearing and vision project . The perception was that large numbers of children were starting school without having had a vision or hearing screen which could impact on their ability to learn .

Priorities for the next 12 months: l Complete screening programme in 2014 . l Analyse data and complete report on project . l Ministry of Education to address name matching issues for the Enrol database so schools can view accurate information . l Plan process for screening children each year at school who miss their four-year-old vision and hearing screen .

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Awhi Midwives and Awhi House Turangi

Aim: The purpose of this programme is to improve the lives of pregnant women, babies and children in the Turangi district .

Background:Awhi House is a single maternal and child health integrated service, designed by and delivered in the Turangi community . A key objective of the service is to ensure that the health services are integrated, coordinated and effectively targeted for Maori and that Maori are assisted to ensure that pepi, mokopuna and tamariki have the best start to life .The activities and initiatives to be delivered through this service specifically focus on achieving health equity and health gains for Maori in the Turangi district . These activities include (and are measured on):

l Improved timing of registration with a lead maternity carer (LMC) and early engagement of pregnant women in maternity services . l Reduced rates of smoking in pregnancy . l Improved pregnancy education and early parenting education . l Improved maternal mental health through mental health needs screening and referral . l Screening to identify and reduce incidence and impact of family violence issues, drug and alcohol and addictions and referral . l Promotion of healthy eating and exercise, incorporating new health promotion activities and opportunities that become available, including shaken baby programme and safe sleeping programme . l Improved breast feeding rates . l Promoting and enabling healthy attachment between families / whanau and their babies / pepe . l National immunisation health targets achieved for the target population . l Improved Well Child Tamariki Ora check coverage rates . l Improved post natal contraception service . l Improved multi disciplinary and collaborative environment between relevant maternal and child health providers and social services in Turangi . l Practical support services including home visiting mothercraft for mothers whanau and newborn babies . l To ensure pregnant women have the opportunity to be dentally fit in pregnancy and pass on good oral habits to their children .

Benefits to Lakes DHB community:There is a large body of evidence that points to the importance of pregnancy and the first few years of life in setting a foundation for future learning, behaviour and health . This includes moving intervention to an earlier stage in the life course to support prevention and early intervention which is both more effective and cost effective . Pregnant women and families with children up to six years are able to go to Awhi House and have their care met in a preventative, holistic, integrated, coordinated and facilitated manner .

44

Our Results: The service has been running since 1 February 2014. In the first two months a significant level of need in the Turangi community was uncovered with increased and unplanned presentations through the advertising and promotions of this service . Developments since the start have highlighted a need for care of women and their babies during the day, earlier intervention from Well Child Tamariki Ora services than the usual four to six weeks and a need for a practical community support worker . Additionally the house has attracted a group of volunteers from the Turangi community to provide support, food and baby clothes and equipment which women can have or exchange . Being monitored is the week of pregnancy which pregnant women book in. There is an early trend reflecting women booking in earlier in their pregnancy . Also is the monitoring of smoking in pregnancy and smoking status between booking in and delivery, there is also a trend here of less women at delivery being classed as smokers . To date seventy pregnant women have enrolled in the service and are benefiting along with their newborn babies and wider families .

Background:There are approximately 50 babies born annually in Turangi and surrounding areas . This is an area of high deprivation and high Maori population . Child health inequalities are over represented in this population including low birth weight babies, poor antenatal care, smoking in pregnancy, Special Baby Care Unit admissions, poor oral health and Sudden Unexpected Deaths in Infancy (SUDI) . Contributing to this has been the historically poor and inconsistent maternal and child health service provision in Turangi The 2012 Taupo Maternity Facility and Service implementation report recommended Lakes DHB develop a sustainable model of service delivery to Turangi pregnant women . In 2013 Lakes DHB successfully completed a consultative process to develop a maternal and child health services integration programme . This included providing a co-location sites for maternal and child health services to be delivered from in a coordinated and facilitated manner in Turangi . The strategic direction and service specifications were approved by the Ministry of Health. It will facilitate and coordinate a pathway for pregnant women children and whanau through the available services to prevent adverse outcomes and achieve health and wellbeing . These services include health, social and education .

Priorities for the next 12 months:Increase home visiting and intensive home visiting services .

45

Section Three - FUTURE FOCUS

46

Action Plan

Quality and patient safety are a top priority for Lakes DHB . The ongoing actions of staff are critical to patient safety .We are committed to implementing the initiatives specified by the Health Quality and Safety Commission . All DHB staff, clinical leaders and managers are responsible for improving quality and participating in quality improvement initiatives and projects .

The key work areas are: l Continuing to keep our patients safe - By participating in the national patient safety campaign – reducing falls resulting in harm, reducing surgical site infection, reducing peri-operative harm (including safety in theatres and VTE) and reducing medication errors - Improving our hand hygiene compliance - Reducing the number of patients who develop a pressure injury whilst in hospital - Minimising seclusion practice in mental health l Continuing to improve the quality of end of life care for our patients l Continue to work to improve our escalation process when a patient’s condition deteriorates l Improve our customer care and responsiveness to patient needs

The above areas were chosen because of the common themes identified from our serious event investigations or because our patients raised them as concerns .Quality of care, listening to consumers and community and preventing harm are at the centre of Lakes DHB quality improvement plan . This work is directed from a clinical governance framework but informed by a clinical area up approach .

The New Zealand Triple Aim

QUALITYIMPROVEMENT

47

Lakes DHB has recently launched “The Lakes Way” - a commitment to our patients which will govern our approach for the foreseeable future .

We will treat you and your family with respect We will make choices available to you We will treat you with dignity We will respect your individual beliefs

BE KIND Introduce myself, my role Consider things from the other person’s point of view Respect privacy Respect pain and grief Respect people’s dignity by imagining what we would want for our family

We will ensure our environment is clean and tidy

We will ensure our signs and instructions are clear

We will listen

We will keep you informed

We will answer your questions

BE RESPONSIVE Respond in a timely manner Offer to help Keep your word Value the patient’s time Acknowledge people’s concerns Apologise if we didn’t get it right Explore realistic timeframes

We will establish mechanisms so that patients can feedback to us to improve

We will review incidents and act on learning

We will keep you safe

We will provide you with the best possible care

MAKE A DIFFERENCE Take responsibility Choose a positive attitude Ask for feedback Can do, look for solutions Speak up about unsafe care Learn from mistakes Support people who speak up

Learn from our mistakes Support people who speak up Train professional teams Equip our teams We will put the patient’s safety first We will review our performance on a regular basis Allow time for staff to provide safe care

HOW WE WILL BEHAVE

OUR PROMISE TO YOU AS A PATIENT

HOW THEORGANISATION

SUPPORTS

January 2014

48

Statement of Intent

Do you have feedback?

Do you have suggestions about what you would like to see in future Quality Accounts?This report will be made available to the community via our website www .lakesdhb .govt .nz and copies will be circulated to local GP surgeries and to Rotorua and Taupo Public Libraries .

If you would like your own copy please contact the Lakes DHB Quality and Risk team by emailing feedback@lakesdhb .govt .nz

We encourage and welcome your views.

There are two ways you can let us know what you think of our progress this year and what you would like us to focus on in the future . You can email:

feedback@lakesdhb .govt .nz

Or write to:

Quality AccountQuality and Risk TeamLakes DHBPrivate Bag 3023Rotorua 3046

www.lakesdhb.govt.nz