HOSPITAL ADVISORY COMMITTEE (HAC) MEETING 4 …...Oct 04, 2017 · 3.6 Balanced Scorecard . Lines 12 & 13 June 2017 – errors in the figures were noted and will be amended next month

Counties Manukau District Health Board – Hospital Advisory Committee

HOSPITAL ADVISORY COMMITTEE (HAC) MEETING 4 October 2017

Venue: Room 101, Ko Awatea, Middlemore Hospital, Hospital Road, Otahuhu Time: 1.30pm Committee Members Dr Lyn Murphy – Committee Chair Dr Ashraf Choudhary – CMDHB Board Member Catherine Abel-Pattinson – CMDHB Board Member Dianne Glenn – CMDHB Board Member Mark Darrow – CMDHB Board Member Rabin Rabindran – Deputy Chair

CMDHB Management Gloria Johnson – acting Chief Executive Phillip Balmer – Director Hospital Services Vanessa Thornton – acting Chief Medical Officer Jenny Parr – Director of Patient Care, Chief Nurse & Allied Health Professions Officer Margaret White, Chief Financial Officer Dinah Nicholas - Secretariat

APOLOGIES

REGISTER OF INTERESTS • Does any member have an interest they have not previously disclosed? • Does any member have an interest that may give rise to a conflict of interest with a matter on the agenda?

PART 1 – Items to be considered in public meeting

AGENDA

1. AGENDA ORDER AND TIMING Page No.

2. CONFIRMATION OF MINUTES 1.30pm 1.35pm

2.1 Confirmation of Minutes of the Hospital Advisory Committee Meeting – 23 August 2017

2.2 Action Items Register

6-10

11-12

3. PROVIDER ARM PERFORMANCE REPORT 1.40pm 2.00pm 2.10pm 2.20pm 2.30pm 2.40pm 2.50pm 3.00pm 3.10pm 3.15pm

3.1 Executive Summary (Phillip Balmer) 3.2 Project Initiatives 3.3 Balanced Scorecard 3.4 Finance Report (Margaret White) 3.5 Emergency Department, Medicine and Integrated Care (Brad Healey) 3.6 Surgery, Anaesthesia and Perioperative Services (Mary Burr) 3.7 Central Clinical Services (Ian Dodson) 3.8 KidzFirst and Women’s Health (Nettie Knetsch) 3.9 Adult Rehabilitation and Health of Older People (Dana Ralph-Smith) 3.10 Mental Health and Addictions (Tess Ahern) 3.11 Facilities (Philip Balmer) 3.12 Middlemore Central (Dot McKeen)

13-19 20-22 23-25 26-29 30-36 37-40 41-43 44-51 52-54 55-59 60-62 63-65

Afternoon Tea Break (3.25 – 3.35pm)

4 CORPORATE REPORTS 3.35pm 3.45pm

4.1 Director Patient Care, Chief Nurse and Allied Health Professions Officer (Jenny Parr)

4.2 Human Resources Report (Phillip Balmer)

66-79 80-82

3.50pm 5. RESOLUTION TO EXCLUDE THE PUBLIC 83

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Counties Manukau District Health Board – Hospital Advisory Committee 4 October 2017

BOARD MEMBER ATTENDANCE SCHEDULE – HAC 2017

Name

Jan Feb 8 Mar 19 April 31 May June 12 Jul 23 Aug Sept 4 Oct 15 Nov

Dr Ashraf Choudhary

Catherine Abel-Pattinson (Deputy Chair HAC)

Dianne Glenn

Dr Lyn Murphy (Chair HAC)

Mark Darrow

X

Rabin Rabindran

External Appointee TBC - - -



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Counties Manukau District Health Board – Hospital Advisory Committee 4 October2017

HAC MEMBERS DISCLOSURE OF INTERESTS

4 October 2017 Member Disclosure of Interest

Dr Lyn Murphy (HAC Chair) • Member, ACT NZ

• Director, Bizness Synergy Training Ltd • Director, Synergex Holdings Ltd • Trustee, Synergex Trust • Member, International Society of

Pharmacoeconomics and Outcome Research (ISPOR NZ)

• Member, New Zealand Association of Clinical Research (NZACRes)

• Senior Lecturer, AUT University School of Inter professional Health Studies

• Member, Public Health Association of New Zealand Dr Ashraf Choudhary

• Board Member, Otara-Papatoetoe Local Board • Member, NZ Labour Party • Chairperson, Advisory Board Pearl of Island

Foundation • Co-Patron, Bharatiya Samaj Charitable Trust

Catherine Abel-Pattinson (HAC Deputy Chair)

• Board Member, Health Promotion Agency • National Party Policy Committee Northern Region • Member, NZNO • Member, Directors Institute

Dianne Glenn • Member, NZ Institute of Directors • Life Member, Business and Professional Women

Franklin • Member, UN Women Aotearoa/NZ • President, Friends of Auckland Botanic Gardens and

Chair of the Friends Trust • Life Member, Ambury Park Centre for Riding

Therapy Inc. • Vice President, National Council of Women of New

Zealand • Justice of the Peace • Member, Pacific Women’s Watch (NZ) • Member, Auckland Disabled Women’s Group

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Counties Manukau District Health Board – Hospital Advisory Committee 4 October2017

Mark Darrow

• Chairman, Primary Industry Training Organisation Incorporated (ITO)

• Chair, Remuneration Committee, Primary ITO • Ex officio, Finance and Audit Committee, Primary

ITO • Independent Director, Motor Trade Association • Chair, Investment Committee, Motor Trade

Association • Director, New Zealand Transport Agency (NZTA) • Chair, Finance and Audit Committee, NZTA • Independent Director, Balle Bros Group • Chair, Finance and Audit Committee, Balle Bros

Group • Member, Investment Committee, Balle Bros Group • Director, Advisory Board, Courier Solutions Ltd • Chairman, The Lines Company Ltd • Chair, Remuneration Committee, The Lines

Company Ltd • Chairman, Armstrong Motor Group (Advisory Board) • Director, MCD Capital Ltd • Chairman, Signum Holdings Ltd • Chairman, Toloda Properties Ltd • Trustee, Tudor Park Trust • Director, Tudor Park Farm Ltd • Justice of the Peace

Rabin Rabindran

• Chairman, Bank of India (NZ) Ltd • Director, Auckland Transport • Director, Solid Energy NZ Ltd • Director, Swift Energy NZ Ltd • Director, Swift Energy NZ Holdings Ltd • Director, Kowhai Operating Ltd • Director, NZ Liaoning International Investment &

Development Co Ltd • Singapore Chapter Chairman – ASEAN New Zealand

Business Council External Appointee TBC

External Appointee TBC

External Appointee TBC

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HOSPITAL ADVISORY COMMITTEE MEMBERS’ REGISTER OF DISCLOSURE OF SPECIFIC INTERESTS Specific disclosures (to be regarded as having a specific interest in the following transactions) as at 4 October 2017 Director having interest Interest in Particulars of interest Disclosure date Board Action Dr Lyn Murphy

Allied Health Initiative for Education & Development (AHIED)

Senior Lecturer, AUT School of Inter-Professional Health Studies

30 November 2016 8 March 2017

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

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Minutes of Counties Manukau District Health Board

Hospital Advisory Committee Held on Wednesday, 23 August 2017 at 2.35pm

Room 101, Ko Awatea, Middlemore Hospital, Hospital Road, Otahuhu, Auckland

PART I – Items considered in Public Meeting

BOARD MEMBERS PRESENT

Lyn Murphy (Committee Chair) Ashraf Choudary Catherine Abel-Pattinson Dianne Glenn Mark Darrow Rabin Rabindran

ALSO PRESENT

Phillip Balmer (Director Hospital Services) Margaret White (Chief Financial Officer) Gloria Johnson (acting Chief Executive) Vanessa Thornton (acting Chief Medical Officer) Janet Haley (Senior Communications Advisor) Dinah Nicholas (Secretariat) (Staff members who attended for a particular item are named at the start of the minute for that item)

PUBLIC AND MEDIA REPRESENTATIVES PRESENT

There were no public or media present at this meeting. APOLOGIES

An apology was received and accepted from Jenny Parr.

DISCLOSURE OF INTEREST/SPECIFIC INTERESTS

The Disclosures of Interest were noted with no amendments. There were no specific interests to note with regard to the agenda for this meeting.

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1. AGENDA ORDER AND TIMING

Items were taken in the same order as listed on the agenda.

2. COMMITTEE MINUTES 2.1 Confirmation of the Minutes of the Hospital Advisory Committee meeting held on 12 July

2017 Resolution (Moved: Dianne Glenn/Seconded: Catherine Abel-Pattinson) That the minutes of the Hospital Advisory Committee meeting held on 12 July 2017 be approved. Carried

2.2 Action Item Register

Noted. 3. PROVIDER ARM PERFORMANCE REPORT

Phillip Balmer introduced the report.

3.1 Deep Dive into Demand Pressures for Medicine and Surgery

This item was discussed in the Public Excluded section of this meeting.

3.2 Emergency Department, Medicine and Integrated Care Discharge Lounge – the 11am discharge rates have improved and been sustained over the last three months. Overall, the trend indicates a steady move towards the target. 3pm rapid rounds and nurse facilitated discharges are strategies currently being used. Doctor roster changes will also result in timely decision making to support early discharges.

3.3 Surgery, Anaesthesia and Perioperative Services The report was noted and taken as read.

3.4 Executive Summary

Women’s Health & Kidz First – in line with our strategic goal of reducing inequities and adding life years, the division’s achievement in reducing Sudden Unexplained Death in Infants (SUDI) for Maaori babies through their implementation of the regional SUDI Safe Sleep programme of work is a standout success worth celebrating.

3.5 Initiative Programme Update Savings achieved from planning 2016/17 initiatives totalled $12.4m against a target of $14.7m for the year. This represents a delivery result of 85% against target. There is a commitment to continuous improvement and to carry these projects through to 2017/18 along with new initiatives.

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3.6 Balanced Scorecard

Lines 12 & 13 June 2017 – errors in the figures were noted and will be amended next month.

3.7 Finance (Margaret White)

Important to note that the Provider Arm came through $2.9m favourable to budget for the year. That was in response to a request from the organisation that the Provider Arm share the pain as we had some unfavourable positions within the Funder late 2016 so this was a good demonstration of working collectively. There are some particularly big movements in the month of June which characterises our year adjustments. One area continuing to see pressure is nursing staff, we need to make sure we have a clear strategy to address this when we think about resourcing going forward.

3.8 Central Clinical Supplies

Radiology – workforce pressures are creating challenges in terms of providing timely access with services prioritising acute work which means that some of the GP referrals and others are not being delivered in the same way as we have in the past. Turnover has dropped back in the last few months but inevitably, this workforce pipeline and using the facilities we have is an important challenge going forward.

3.9 Women’s Health & Kidz First

MCIS – we have been working very closely with MCIS and the Ministry although not really progressed very far with them. We are hoping to get a commitment from the Ministry that we will get support to improve the MCIS. It is important to be aware that this is a system that is causing a lot of clinical concern. At the moment we are trying to persist with improving the electronic system because backing out completely would also cause a lot of problems for the organisation. It is an area that has been very slow moving and we are anticipating that the upcoming election will slow things down even further. Midwifery – a provisional report on the current midwifery shortage (national and by DHB) reflects a large shortage and will likely require a new strategy for training and retaining this workforce. CM Health has shortages in our employed senior midwifery positions as well as LMC shortages. The Directors of Midwifery met late July to start to develop an urgent retention strategy. Caesarean Section Rate – the organisation’s CS rate for June was 28%, compared to YTD rate of 26% against 23% last year. Our rates remain significantly lower than other DHBs across the region and this is because we will only do Caesarean Sections for medical reasons, rather than patient choice. Complications have increased particularly morbid obesity, older mothers and diabetes in pregnancy.

3.10 Adult Rehabilitation and Health of Older People

Spinal Inpatient ACC Revenue – it was noted that the ACC revenue for June was slightly lower than projected due to a lower number of patients coming through which is predominantly because of seasonal variation, we see a lot more patients in summer. Some of the ACC

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patients are also in our system for 4-6 week and are not coded until discharge so often the revenue won’t come through until the next month.

3.11 Mental Health and Addictions

Mental Health Measure Action Item Response – it was noted that a further update will be provided to the Committee on 15 November. Maternal Mental Health Model of Care - the Committee noted that the Maternal Mental Health team recently received the Mental Health Nursing Service Award for the work the team have completed to develop a clear and contemporary model of care. The team have worked in collaboration with their NGO partner and now have improved access to Maternal Mental Health support for women when pregnant or with a new baby. This work was undertaken as a result of the Counties Manukau Maternal Mental Health service review completed in 2015. The Committee agreed to send a letter of congratulations to the team. NZ HR Award to Mental Health Nursing Education Team the Mental Health Nurse Education Team were recently awarded the NZ HR Award for ‘Learning and Development Capability in the Public Sector’ for the development of the National Safe Practice Effective Communication training package. The Committee agreed to send a letter of congratulations to the team.

3.12 Facilities Galbraith Building – there are currently a number of reviews being undertaken by BECA Consulting in relation to the Galbraith Building:

1. A detailed seismic review against the new earthquake standards that will come up with a set of recommendations of what our options are for improving its seismic rating.

2. A critical infrastructure site survey - all the hospital main gas, oxygen, water etc comes through the Galbraith building. The site survey is to develop a plan that would enable us to either move those services or to protect them so they were not damaged in the event of an earthquake.

3. An asbestos review (BECA Consulting with an independent agent providing oversight) starting with Galbraith with the intent to undertake a full survey across all our sites.

We need to know what strengthening work needs to be done, how good that will make the building and how quickly it can be done. We also need to ensure that any strengthening won’t disturb any asbestos or will require decanting of patients and/or staff. The BECA reports will come to Gloria, Phillip and Rabin Rabindran who will okay what work will be undertaken. Recladding – Mr Balmer to bring back a Facilities Stocktake paper to the next HAC meeting (4 October) which will reflect which buildings appear to have potential weather seal, build and/or passive fire protection issues with an indication of costs to remediate.

3.13 Middlemore Central

Mr Balmer to bring the headlines from the 2017 Winter review plan to the next HAC meeting (4 October).

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4. CORPORATE REPORTS 4.1 Director Patient Care, Chief Nurse and Allied Health Professions Officer

The Committee agreed that a letter of congratulations be sent to Akshat Shah, a Middlemore-based Speech Language Therapist who recently won the University of Auckland 3-minute Thesis Masters Final. Akshat spoke on the effectiveness of a workshop to improve community speech language therapists’ ability to assess and provide appropriate intervention for children with cleft palate speech disorders. Akshat will now represent the UoA at the Masters 3MT Inter-University Challenge to be hosted by Victoria University on 24 August. Diversity Ball – the Committee asked that next year a Board table be reserved at the Diversity Ball.

4.2 HR Report The report was taken as read. 4.2 Q4 Non-Financial Summary Report

The report was taken as read. The Chair thanked everyone for their contributions to today’s meeting. The meeting closed at 3.45pm

SIGNED AS A CORRECT RECORD OF THE COUNTIES MANUKAU DISTRICT HEALTH BOARD HOPSITAL ADVISORY COMMITTEE MEETING OF 23 AUGUST 2017. Lyn Murphy, Committee Chair

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Items once ticked complete and included on the Register for the next meeting, can then be removed the following month.


Hospital Advisory Committee Meeting – Public Action Items Register – 4 October 2017

DATE ITEM ACTION DUE DATE RESPONSIBILITY COMMENTS/UPDATES COMPLETE

Standing Items

12.7.17 2.4 Summary of Annual Leave Cash-Ups for Hospital Services Directorate – provide a quarterly report showing, for those staff that have had annual leave paid out, their current leave balance, leave accrual and leave taken. This report will not specifically identify particular individuals due to privacy issues.

4 October Margaret White/ Phillip Balmer

Refer Item 4.2 on today’s agenda.

31.5.17 5.1 Certification – provide a quarterly report showing progress being made against each corrective action.

15 November Jenny Parr

12.7.2017 6.11 Medicine - Bowel Screening Programme regular update each meeting.

4 October Brad Healey Refer Item 3.5 on today’s agenda.

12.7.2017 2. Patient Survey –regular update on the response rates to the patient survey and the complaints review process.

4 October Jenny Parr Refer Item 4.1 on today’s agenda.

12.7.2017

6.1 Hospital Services 2016/17 Project Initiatives Quarterly report including specific bed day savings and benefits realisations. Update (as part of the Executive Summary).

4 October 15 November

Phillip Balmer


12.7.2017 5.1 System Level Measures Quarterly full report. Update (as part of the Executive Summary).

4 October 15 November

Phillip Balmer


31.5.2017/ 12.7.2017

5.1 Acute Psychiatry – provide a regular report on how the DHB measures itself against the UK Mental Health Triage Scale model (ie) responses to triage times (how many people that were triaged E we did actually see within 4 weeks). The service is currently facing some technological issues in measuring some of this data accurately and is

15 November Phillip Balmer/ Tess Ahern

23.8.17 – the audit of wait times against the triage scale has revealed a number of process issues that need to be rectified. A further update will be provided in three month’s time.

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Items once ticked complete and included on the Register for the next meeting, can then be removed the following month.


DATE ITEM ACTION DUE DATE RESPONSIBILITY COMMENTS/UPDATES COMPLETE

undertaking an audit to ensure the data is being measured correctly. Come back with a proposal based on the audit, when completed.

12.7.2017 4.1 Health of Older People – provide statistical data on the programmes mentioned on 12 July by Shankar Sankaran in the HoP monthly report.

15 November Phillip Balmer/ Dana Ralph-Smith

23.8.17 - A full complement of data will be reported to HAC following completion of Q1 2017/18.

12.7.2017 6.2 HR – bring information back on the number of health professionals moving between NZ and Australia.

4 October Phillip Balmer 23.8.17 – No verbal was provided at this meeting so deferred.

X

23.8.2017 3.11 Mental Health – send letters of congratulations to the Maternal Mental Health team and the Mental Health Nurse Education Team.

4 October Dinah Nicholas Letters were sent 1.9.17 from the HAC Chair.

23.8.2017 3.12 Facilities – bring back a Facilities stocktake paper which will reflect which buildings appear to have potential weather seal, build and/or passive fire protection issues with an indication of remedial costs.

4 October Phillip Balmer Refer Item 3.2 in the Confidential section of today’s meeting.

23.8.2017 3.13 Middlemore Central – bring the headlines from the 2017 Winter review plan for discussion.

4 October Phillip Balmer Refer Item 3.12 on today’s agenda.

23.8.2017 4.1 Director of Patient Care – send a letter of congratulations to Akshat Shah, Middlemore-based Speech Language Therapist. Ensure next year a Board table is reserved at the Diversity Ball.

4 October 4 October

Dinah Nicholas Jenny Parr

A letter was sent 1.9.17 from the HAC Chair. Refer Item 4.1 on today’s agenda.

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Counties Manukau District Health Board Hospital Advisory Committee

Hospital Services Report

Recommendation It is recommended that the Hospital Advisory Committee: Receive the Hospital Services Report covering activity in August 2017. Prepared and submitted by Phillip Balmer, Director Hospital Services Executive Summary Glossary

CHF Congestive Heart Failure COPD Chronic Obstructive Pulmonary Disease DHB District Health Board ED Emergency Department FCT Faster Cancer Treatment GP General Practitioner/General Practice HRT Health Roundtable KPI Key Performance Indicator LOS Length of Stay MMH Middlemore Hospital PHO Primary Health Organisation SLM System Level Measures Overview

The challenges associated with the high volumes and acuity we have experienced in recent months have been a consistent theme throughout our reporting to the Hospital Advisory Committee. While these challenges continue to be reflected in our August performance, signs of relief are beginning to show – with only five ‘hospital full days’ reported for the month. We are working hard to apply our learnings from this winter in a number of ways; Middlemore Central is again orchestrating the development of the Winter Lessons Learned Report (a particularly useful tool for service-level planning), we have initiated a time-limited Facilities Master Planning project to confirm our capacity requirements over the next 3-5 years and align our facility investments accordingly, and we are actively contributing to the Regional Long Term Investment Planning process underway. The hospital-wide balanced scorecard, finance, and human resources reports included in this report provide a consolidated view of organisational performance, and we have also provided a high level overview of our 2017/18 initiatives programme. For my Executive Summary this month I have chosen to highlight performance in two key areas; the Emergency Department six hour target, and the acute bed days SLM.

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Financial Position

The Provider Arm has delivered a favourable financial result of $67k for the month of August. We are also favourable $417k for the year to date. We remain focussed on maximising revenue opportunities and improving efficiencies to return the DHB to a breakeven position. Further detail on our financial performance is included in the ‘Financial Results’ section of this month’s report. Initiatives Portfolio

Delivery of our 201718 initiatives workplan is well underway; we have a total of 133 projects being regularly monitored, ranging from local improvement initiatives through to major transformational programmes of work. It is particularly pleasing to see 47 of these projects already in the execution phase. Also of note is the realisation of financial benefits associated with our initiatives portfolio. At the end of August we had achieved 90% of our YTD target, which equates to $2.42M. Further detail is provided in the ‘Initiatives Programme’ section of this month’s report. National Health Targets

Performance against the three national health targets for which the Hospital Services Directorate is responsible for is summarised below. Elective Surgery

Description The volume of elective surgery will be increased by an average of 4,000 discharges per year.

July (confirmed)

Not achieved 99.3%

August (indicative)

Achieved 100%

Note: Performance against the Elective Surgery target is reported one month in arrears. A variation of 11 from planned volumes has resulted in us not meeting the target for July. Performance is back on track for August. Faster Cancer Treatment

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

August (indicative)

Not achieved 84%

During August there were four breaches resulting from capacity constraints. The FCT programme focus remains on seeking and implementing sustainable pathway improvements, as measured by the FCT data. This has resulted in a reduction in capacity-related delays, but there are still some reported each month. The programme is moving through a sustainability review phase at present. As the only reportable breach reasons are now capacity-related, we remain focused on achieving our internal target of 100% performance using the new reporting criteria.

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Emergency Department

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

August Not Achieved 89%

Continued high volumes of both presentations (increase of 3.4% from August 2016) and hospital occupancy have again meant the ED has been unable to achieve the target. Work is underway to rapidly assess our current capacity and forecasted demand for the next three to five years; this will inform short-term investment in expanding our capacity in time for next winter, which will have a flow on effect of improving patient flow through the system. Between June 2011 and June 2017, our total ED presentations have increased by 27%. Although we have recently been unable to meet the 95% target, the volume of patients who have been seen within the six hour timeframe is higher than ever before (see following table and graph). Total ED presentations in June, by year:

2011 2012 2013 2014 2015 2016 2017

Total ED discharges <6 hours 7,802 8,425 8,319 8,608 8,836 9,072 9,464

Total ED discharges >6 hours 318 281 297 388 359 332 871

Total ED presentations 8,120 8,706 8,616 8,996 9,195 9,404 10,335

% discharges <6 hours 96% 97% 97% 96% 96% 96% 92%

% discharges <6hrs 4% 3% 3% 4% 4% 4% 8%

7,000

7,500

8,000

8,500

9,000

9,500

10,000

10,500

Jun-11 Jun-12 Jun-13 Jun-14 Jun-15 Jun-16 Jun-17

ED P

rese

ntat

ions

ED stay longer than 6 hours

ED stay within 6 hours

ED stay within 6 hours in 2017exceeds all previous years'total ED presentation

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System Level Measures

Overview

Significant progress has been made in a collaborative project between primary and secondary care to improve outcomes for patients with chronic conditions including COPD, CHF, Cellulitis, and Stroke. The focus of these improvement initiatives is to reduce acute demand in terms of ED presentations and acute bed days and to reduce amenable mortality. The workplans are aligned both locally and regionally. Workshops are being held with representatives from PHOs, GPs, DHBs, and others to engage clinical teams with the respective workplans and to develop monitoring metrics.

SLM Key Performance Indicators for reducing acute bed days

The Health Roundtable compares performance against a range of KPIs across 150 hospitals in Australia and New Zealand. The most recent Hospital KPI Report was released in September, covering performance for the year July 2016 to June 2017 (see results below). Extracts from the HRT report associated with each KPI are included after the following table.

KPI Goal Result Accountable

1. Reduce long stay share of bed days > 21 days <10% 9.1% Stranded patient working group

2. Reduce inpatient readmissions <7% 6.3% SLM working group

3. Inpatient discharge by 11am >30% 34% Middlemore Central Governance Group

4. Reduce acute average length of stay <2.7% 2.6% All Divisions

5. Time from ED presentation to disposition <6 hrs 95%

<6 hrs 95%

All Divisions

6. Time from ED presentation to admission <6 hrs 95%

<6 hrs 94%

All Divisions

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017


018


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Initiatives Programme Glossary

ACC Accident Compensation Corporation ARHOP Adult Rehabilitation and Health of Older People ASH Ambulatory Sensitive Hospitalisation CHF Congestive Heart Failure DNA Did Not Attend FCT Faster Cancer Treatment LOS Length of Stay MOC Model of Care POAC Primary Options for Acute Care POC Point of Care SLM System Level Measures Overview

Moving into FY17/18, Hospital Services is undertaking an ambitious workplan consisting of a number of service-led transformation, improvement, and revenue initiatives aligned with our Healthy Together strategy. A number of these are building and continuing with projects already underway, while others have been established to drive our strategic goals around improving services for patients, and maintaining financial sustainability. Each of these initiatives has identified benefits (either financial benefits, non-financial benefits, or both) which are being tracked, and a standardised process whereby all active Hospital Services initiatives are reported on each month by the respective managers is in place. Plans for 2017/18

As part of delivering Healthy Together 2020, three strategic portfolios of work have been established; Excellent Care, Infrastructure and Assets, and Service Improvement. These represent the strategic investment areas for CM Health. Nine key outcome areas have also been identified which work will align to. These cover the improvement of SLMs, as well as providing safe high-quality healthcare, technology enablement to improve systems and processes, regional design for services, and improving revenue.

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Delivery progress

Delivery of the 2017/18 workplan is well underway now. Across the Hospital Services Directorate and related programmes, there are 133 total projects being monitored, which range from localised service improvements through to major transformational activities. There are 31 projects currently in initiation, which largely relate to new project focus areas for 2017/18 which are being established. Breakdown of project delivery by Division, August ’17:

Division / Programme Phase

Initiation Planning Execution Close Out Benefits Realisation

On Hold Total

ARHOP 2 2 2

6

Central Clinical Services

3

1 1 5

Emergency Care, Medicine and Integrated Care

9 2 5 1

2 19

Facilities and Asset Management 4 8 7 2

1 22

Healthy Together Tech. (Hospital Services) 2 3 5

3 13

Hospital Services Information Systems

1 2 1

4

Kidz First and Women's Health

2 5 1 1

9

Mental Health and Addictions 6 1 3 4

1 15

Middlemore Central 1 1 1

1 1 5

Surgical, Anaesthesia and Perioperative Care 3 6 14 2 1 5 31

System Level Measures Improvement Prog. 4

4

Grand Total 31 26 47 11 4 14 133

For future Hospital Advisory Committee reports, the movement of 2017/18 projects through their lifecycle will be demonstrated, in terms of month-on-month movement. The following graph shows the number of initiatives within each division, and the current status of these projects:

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Benefits Realisation

The full year financial benefit target for CM Health is $30.367M across all areas of the organisation. In total, $17.677M of this target is directly attributable from Hospital Services initiatives (excluding cross-directorate and whole of system benefits) Monthly tracking and reporting is in place across all of these initiatives, with regular reporting to the Executive Leadership Team now in place identifying any issues around benefit realisation, and how these are being mitigated. Of the $17.677M of benefits being delivered directly through Hospital Service initiatives, a performance breakdown is presented below. Hospital Services Benefits Delivery at end of August ’17 (Month Two):

Division Full Year Target ($M)

YTD Target ($M)

YTD Actual ($M)

Variance ($M)

% of Target Delivered

ARHOP 1.004 0.167 0.318 0.151 190%

Central Clinical Services 0.110 0.018 0.018 0.000 100%

Emergency, Medicine, Integration 0.869 0.145 0.000 -0.145 0%

Facilities Management 2.170 0.283 0.021 -0.263 7%

Hospital Services (Cross Divisional) 0.986 0.000 0.000 0.000

Kidz First 0.547 0.091 0.091 0.000 100%

Mental Health and Addictions 0.890 0.148 0.278 0.130 188%

Middlemore Central 0.238 0.040 0.000 -0.040 0%

Non-Clinical 6.100 1.017 1.078 0.061 106%

Surgery, Anaesthetic and Perioperative Services 3.986 0.664 0.489 -0.175 74%

Women’s Health 0.777 0.130 0.130 0.000 100%

Grand Total 17.677 2.704 2.423 -0.280 90%

Across the whole Hospital Services Directorate, 90% of the target benefit for the first two months of the financial year has been delivered. Mitigations are in place across all intiatives to ensure that benefits are delivered as per plan, and where this is not possible, alternative benefit avenues are considered. Additionally, a three year pipeline of savings opportunities is being developed, to provide a longer term picture of where benefits can be delivered.

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HOSPITAL SERVICES BALANCED SCORECARD August 2017*Red variance figures: non-favourable result for the indicator

NOTES* performance is against previous year's actual∆ ESPI interim results subject to change

Trend by monthFY17-18 Aug-17 Target Var Actual Target Var

Emergency Department - 6 hour Length of Stay target 89% 95% -6% 87% 95% -8%FCT % of high suspicion first cancer treatment within 62 days (indicative result) 84% 90% -6% 93% 90% 3%Elective surgery discharges 1,363 1,227 11.1% 2,584 1,227 110.6%


Total Caseweight 7,671 7,883 -2.7% 15,420 15,462 -0.3%Acute Caseweight 6,113 6,270 -2.5% 12,505 12,387 1.0%Elective Caseweight 1,558 1,613 -3.4% 2,915 3,075 -5.2%Total Discharges - performace compared to prior year. 9,356 8,854 5.7% 18,520 17,780 4.2%Outpatient First Specialist Assessment Volumes 4,495 4,636 -3.0% 8,469 9,202 -8.0%Outpatient Follow Up Volumes 12,014 10,970 9.5% 22,381 21,855 2.4%Virtual First Specialist Assessments (GP consult and nonpatient appointments) 472 391 20.7% 902 762 18.4%Budgeted FTEs 6,359 6,271 -1% 6,359 6,225 -2%Operating Costs ($000) $27,300 $27,766 2% $54,425 $55,289 2%Personnel Costs ($000) $52,911 $53,250 1% $102,409 $103,269 1%Financial Result Total ($000) -$3,614 -$3,681 2% -$3,465 -$3,882 11%Reduce clinical outsourcing ($000) $2,450 $2,362 -4% $4,606 $4,765 3%

Trend by monthFY17-18 Jul-17 Target Var Actual Target Var

Excess Annual Leave dollars ($000) - estimated cost for excess $3,831 $1,128 -$2,703 $3,607 $1,207 -$2,400Adult Rehabilitation and Health of Older People $61 $74 $13 $71 $85 $14Medicine, Acute Care and Clinical Support $432 $254 -$178 $465 $310 -$155Surgical and Ambulatory Care $1,423 $447 -$976 $1,436 $469 -$967Mental Health $325 $175 -$150 $311 $171 -$140Women's Health and Kidz First $646 $177 -$469 $686 $172 -$514

% Staff Annual Leave >2 years 11.8% 5.0% -6.8% 11.5% 5.0% -6.5%Adult Rehabilitation and Health of Older People 4.1% 5.0% 0.9% 4.2% 5.0% 0.8%Medicine, Acute Care and Clinical Support 8.5% 5.0% -3.5% 7.5% 5.0% -2.5%Surgical and Ambulatory Care 15.9% 5.0% -10.9% 15.3% 5.0% -10.3%Mental Health 9.3% 5.0% -4.3% 9.1% 5.0% -4.1%Women's Health and Kidz First 18.2% 5.0% -13.2% 19.9% 5.0% -14.9%

Natio

nal

Targ

ets

Year to date

Ensu

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Fina

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l Sus

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abili

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Year to date

Enab

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High

Per

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Peop

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Average last 12 months

023



% Staff Turnover (YTD no. voluntary turnovers by average headcount) 9.7% 10.0% 0.3% 10.8% 10.0% -0.8%% Sick Leave 3.2% 2.8% -0.4% 2.9% 2.8% -0.1%Workplace Injury per 1,000,000 hours 5.7 10.5 4.8 11.2 10.5 -0.7

Aug-17 Target Var Aug-16 Target VarWorkforce Population Workforce Population

Maaori 7% 16% -9% 7% 16% -9%Pacific 13% 23% -10% 12% 23% -11%Asian 32% 23% 9% 29% 23% 6%NZ European / non-specified/ other 48% 38% 10% 51% 38% 14%


% e-medication reconciliation - high risk patients within 48hrs (Aug-17) 79% 80% -1% 68% 80% -12%Falls causing major harm rate / 1,000 bed days 0.10 0.00 0.10 0.06 0.00 -0.06Adverse Events: % of admissions affected by ≥4 triggers 1.0% N/A N/A 1.2% N/A N/ACentral Line Associated Bacteraemia (CLAB) rate / 1,000 bed days in ICU (Aug-17) 0.03 0.00 -0.03 0.005 0.00 -0.005Rate of S. aureus bacteraemia rate / 1,000 bed days (Aug-17) 0.13 0.00 -0.13 0.03 0.00 -0.03

Q1 FY17 Target Var Actual Target Var% 75+ years assessed for the risk of falling # 93% 90% 3% N/A N/A N/A% 75+ years assessed for falls risk with falls intervention plans # 96% N/A N/A N/A N/A N/A


% Magnetic Resonance Image (MRI) scans completed within 6 weeks from referral 70% 85% -15% 74% 85% -11%% Computerised Tomography (CT) scans completed within 6 weeks from referral 93% 95% -2% 95% 95% 0%% urgent diagnostic colonoscopy within 14 days 100% 85% 15% 98% 85% 13%% diagnostic colonoscopy patients within 42 days 68% 70% -2% 64% 70% -6%% surveillance colonoscopy patients within 84 days 98% 70% 28% 98% 70% 28%% cardiac STEMI-PCI (angiography) <120mins - Northern Region 89% 80% 9% 85% 80% 5%% Coronary Angiography within 90days (1mth arrears) 85% 95% -10% 87% 95% -8%ESPI 2: No. patients waiting >120 days for FSA - Elective ∆ 16 0 -16 16 0 -16.0ESPI 5: No. patients waiting >120 days treatment - Elective ∆ 14 0 -14 14 0 -14Radiology - Inpatient radiology completion times <24hrs 92% 95% -3% 93% 95% -2%Radiology- Emergency Care radiology completion times <2 hrs 94% 95% -1% 94% 95% -1%FCT - % confirmed diagnosis first cancer treatment within 31 days 92% 85% 7% 93% 85% 8%% Radiology results reported within 24 hours 39% 75% -36% 47% 75% -28%

Firs

t, D

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Year to date

Quarterly reporting Year

Enab

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Hig

h Pe

rfor

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g Pe

ople

(con

t.) Average last 12 months

Workforce DiversityMonth to date

Tim

ely

Year to date

024



Average Length of Stay - Acute Inpatient 3.0 3.0 0.0 3.0 3.0 0.0Average Length of Stay - Acute Arranged/ Elective 1.5 1.4 -0.1 1.7 1.4 -0.3Middlemore Hospital % patients to discharge lounge or home by 1100hrs 21% 30% -9% 21% 30% -10%Acute Readmissions within 7 days - Total 2.6% 2.2% -0.4% 2.6% 2.2% -0.5%Acute Readmissions within 28 days - Total (1 month in arrear) 7.1% 7.1% -0.1% 7.1% 7.0% -0.1%Acute Readmissions within 28 days - 75+ years (1 month in arrear) 11% 12% 1.0% 11% 12% 1.1%Emergency Department Presentations - 75+ year olds 1,173 807 -366 1,189 807 -382% clinical summaries (meddocs) authorised <7 days of creation 70% 95% -25% 70% 95% -25%% of patient outliers - not on home ward <5% 8.6% 5.0% -3.6% 9.2% 5.4% -3.8%

% DHB Mental Health Services - children/ youth (0-19years) seen by 3 weeks for non-urgent 70% 80% -10% N/A N/A N/A

Mental Health access rate - clients seen in last 12 months as % of population (0-19yrs) 4.0% 3.2% 0.9% N/A N/A N/AMental Health access rate - clients seen in last 12 months as % of population (20-64yrs) 3.9% 3.2% 0.8% N/A N/A N/AMental Health access rate - clients seen in last 12 months as % of population (64+yrs) 2.4% 2.6% -0.2% N/A N/A N/A


Outpatient - First Specialist : Follow-up Clinic ratio 37% 42% 5% 38% 42% 4%Outpatient - Did Not Attend rates - Maaori 19% 10% -9% 20% 10% -10%Outpatient - Did Not Attend rates - Pacific 17% 10% -7% 18% 10% -8%Theatre List Utilisation 93% 83% 10% 93% 83% 10%Day of Surgery Admissions (DOSA) 93% 90% 3% 93% 90% 3%Day Case Rate (Elective/ Arranged) 64% 65% -1% 65% 65% 0%% Medical Assessment patients with Length of Stay < 28 hours 76% 65% 11% 77% 65% 12%No. Hospital bed days occupied (against forecast open beds) 22,552 22,814 1.2% 45,684 45,173 -1.1%No. Length of Stay outliers (LOS >10 days)* 378 326 -14% 762 605 -21%


% smokers receive smokefree advice / support -Total 96% 95% 1% 96% 95% 1%% smokers receive smokefree advice / support - Maaori 96% 95% 1% 97% 95% 2%% smokers receive smokefree advice / support - Pacific 94% 95% -1% 96% 95% 1%% smokers receive smokefree advice / support - Asian 97% 95% 2% 96% 95% 1%

% Women (45-60yrs) with Breastscreen in 24months - Total 2766 2400 366 70% 70% 0%% Women (45-60yrs) with Breastscreen in 24months - Maaori 344 289 55 66% 70% -4%% Women (45-60yrs) with Breastscreen in 24months - Pacific 430 377 53 77% 70% 7%

Syst

em In

tegr

atio

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ffec

tive)

Year to date

Quarterly Reporting Year to date

Effic

ient

Year to date

Equi

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Year to date

Volumes Screened % Screened in last 24 months

Trend by month FY17-18 Aug-17 Target Var Actual Target VarPatient experience Survey data very good/excellent - month (n=131) and YTD (n=389) 86% 90% -4% 80% 90% -10%

P&W

CC Year to date

025


Financial Results, August 2017 – Provider Arm Glossary

ACC Accident Compensation Corporation ED Emergency Department FTE Full Time Equivalent LTIP Long Term Investment Plan MoH Ministry of Health WIES Weighted Inlier Equivalent Separation (activity based measurement YTD Year to Date

Actual Budget Variance Variance Actual Budget Variance Actual Budget Variance$(000) $(000) $(000) to Prev $(000) $(000) $(000) $(000) $(000) $(000)

IncomeGovernment Revenue 6,008 5,979 29 F 11,721 11,746 (25) U 65,227 65,227 0 FPatient/Consumer Sourced 821 979 (158) U 1,957 1,988 (31) U 11,846 11,846 0 FOther Income 1,777 2,099 (322) U 3,919 4,387 (469) U 25,548 25,548 0 FFunder Payments 67,991 68,278 (287) U 135,773 136,555 (783) U 819,332 819,332 0 FTotal Income 76,597 77,335 (738) U 153,369 154,676 (1,307) U 921,953 921,953 0 FExpenditurePersonnel 50,951 52,312 1,361 F 99,011 101,387 2,376 F 609,227 609,227 0 FOutsourced Personnel 1,960 939 (1,021) U 3,397 1,882 (1,516) U 11,174 11,174 0 FOutsourced Clinical 2,450 2,362 (87) U 4,606 4,765 159 F 27,352 27,352 0 FOutsourced Other 3,242 3,254 12 F 6,527 6,508 (19) U 39,048 39,048 0 FClinical Supplies (excluding Depreciation) 9,755 10,190 435 F 19,466 19,878 412 F 117,412 117,412 0 FOther Expenses 6,161 6,278 117 F 12,542 12,775 233 F 73,864 73,864 0 FTotal Expenditure (excl Depreciation, Interest and Capital Charge)

74,518 75,334 816 F 145,550 147,194 1,645 F 878,076 878,076 0 F

Earnings before Depreciation, Interest and Capital 2,079 2,001 77 F 7,819 7,482 337 F 43,877 43,877 0 FDepreciation 2,645 2,661 16 F 5,296 5,322 27 F 31,932 31,932 0 FInterest - 27 27 F - 54 54 F 322 322 0 FCapital Charge 3,048 2,994 (54) U 5,988 5,988 0 F 35,928 35,928 0 FTotal Depreciation, Interest and Capital Charge 5,693 5,682 (12) U 11,284 11,364 80 68,182 68,182 0 F

Net Surplus/(Deficit) Provider (3,614) (3,681) 67 F (3,464) (3,882) 417 F (24,305) (24,305) 0 F


Medical Personnel 16,702 17,213 510 F 31,730 33,107 1,377 F 197,785 197,785 0 FNursing Personnel 19,439 19,567 128 F 38,324 38,137 (187) U 230,547 230,547 0 FAllied Health Personnel 6,819 7,112 292 F 13,358 13,934 576 F 84,056 84,056 0 FSupport Personnel 2,376 2,529 153 F 4,600 4,808 208 F 28,776 28,776 0 FManagement/Administration Personnel 5,613 5,891 277 F 11,000 11,400 401 F 68,063 68,063 0 FTotal (before Outsourced Personnel) 50,951 52,312 1,361 F 99,011 101,387 2,376 F 609,227 609,227 0 FOutsourced Medical 876 475 (400) U 1,626 955 (671) U 5,618 5,618 0 FOutsourced Nursing 366 52 (314) U 610 104 (506) U 623 623 0 FOutsourced Allied Health 63 2 (61) U 119 4 (115) U 20 20 0 FOutsourced Support 74 0 (74) U 116 1 (116) U 4 4 0 FOutsourced Management/Admin 581 409 (171) U 926 818 (107) U 4,910 4,910 0 FTotal Outsourced Personnel 1,960 939 (1,021) U 3,397 1,882 (1,516) U 11,174 11,174 0 F

Total Personnel 52,911 53,250 339 F 102,409 103,269 860 F 620,401 620,401 0 F


Central Clinical Services (7,899) (7,643) (256) U (14,780) (14,836) 56 F (89,461) (89,461) 0 FEmergency Medicine and Integration (14,643) (14,511) (132) U (27,988) (27,885) (102) U (165,188) (165,188) 0 FMiddlemore Central (2,533) (2,636) 103 F (4,941) (5,030) 90 F (30,061) (30,061) 0 FARHOP (3,644) (3,569) (75) U (6,950) (7,091) 141 F (42,489) (42,489) 0 FMental Health (5,879) (5,916) 37 F (11,705) (11,835) 130 F (71,441) (71,441) 0 FSurgical & Ambulatory (15,872) (15,861) (11) U (30,437) (30,884) 447 F (187,635) (187,635) 0 FWomen & Child Health (6,074) (6,298) 224 F (11,668) (12,066) 398 F (72,481) (72,481) 0 FFacilities Services (1,964) (1,890) (74) U (3,958) (3,744) (214) U (21,540) (21,540) 0 FProvider Management 60,017 59,718 298 F 118,959 119,519 (560) U 716,071 716,071 0 FInnovations Hub & Ko Awatea (1,329) (1,345) 16 F (2,460) (2,569) 109 F (15,347) (15,347) 0 FIntegrated Care (3,793) (3,730) (63) U (7,537) (7,460) (77) U (44,733) (44,733) 0 FTotal (3,614) (3,681) 67 F (3,464) (3,882) 417 F (24,305) (24,305) 0 F

Surplus / Deficit by Division Month Year to Date Full Year

Consolidated Statement of Financial PerformanceCMDHB Provider

Month Year to Date Full Year

Personnel Costs By Professional Group Month Year to Date Full Year

026


Activity

August was a busy month for inpatient medical services.

• High acute surgical demand especially in General Surgery and Plastics has continued into August. Overall surgical acute WIES was 8.5% higher than contract for the month and 3.9% higher YTD (includes General Surgery, Plastics & Burns, ORL and Ophthalmology, excludes Gynaecology).

• Although higher than last year, acute Paediatric Medicine and Secondary Neonatal WIES are lower than current year contract (combined) as the service is experiencing an easing of recent high demand.

• The unfavourable acute maternity variance is consistent with 34 fewer births compared with the same period last year.

• Elective cardiology volumes are ahead of contract in August as the service clears a backlog of cases following increased acute demand earlier in the year causing elective procedures to be postponed. YTD the service is still below contract.

• The shortfall in elective gynaecological WIES stems from the shortage of theatre space due to acute demand and anaesthetist vacancies.

Finance Overview

The Provider Arm produced a $67k favourable variance against budget for the month of August 2017, YTD $417k favourable. While the YTD result reported a favourable variance, operational performance remains busy as we head toward the end of a very busy winter period that has seen unprecedented acute volumes. A number of upsides have mitigated the impact of the busyness of the hospital including the continuing success of the ACC arrears programme, a favourable movement in creditors, as well as vacancies across the services (part offset by outsourced personnel costs). Major YTD variances are explained below.

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

M00001 - General Medicine Inpatients 1,614 1,582 33 F 2.1% 3,212 3,167 46 F 1.4%S00001 - General Surgery Inpatients 750 716 34 F 4.7% 1,508 1,441 67 F 4.6%S45001 - Orthopaedic Inpatients 658 667 (9) U -1.4% 1,331 1,343 (12) U -0.9%W10001 - Maternity Inpatients 592 612 (20) U -3.3% 1,248 1,167 81 F 6.9%S60001 - Plastic & Burns - Inpatients 494 460 34 F 7.3% 958 927 31 F 3.3%M05001 - Emergency Medical Services Inpatients 394 408 (14) U -3.4% 779 815 (37) U -4.5%M55001 - Paediatric Medicine Inpatients 325 414 (89) U -21.6% 688 807 (119) U -14.8%W06003 - Secondary Neonatal 216 293 (77) U -26.2% 620 587 33 F 5.6%All Others 1,070 1,117 (47) U -4.2% 2,162 2,134 29 F 1.3%Total Acute WIES 6,113 6,270 (157) U -2.5% 12,505 12,387 118 F 1.0%S45001 - Orthopaedic Inpatients 406 433 (27) U -6.3% 862 826 36 F 4.4%S00001 - General Surgery Inpatients 338 390 (52) U -13.4% 625 744 (119) U -16.0%S60001 - Plastic & Burns - Inpatients 303 234 69 F 29.6% 494 446 49 F 10.9%S30001 - Gynaecology Inpatients 108 148 (40) U -27.1% 202 282 (80) U -28.5%S25001 - ORL Inpatients 105 128 (23) U -17.8% 198 244 (46) U -18.8%S40001 - Ophthalmology Inpatients 105 125 (21) U -16.5% 194 239 (45) U -18.9%M10001 - Cardiology - Inpatients 70 59 11 F 18.0% 95 107 (13) U -11.7%S70001 - Urology - Inpatients 39 40 (1) U -3.3% 65 76 (11) U -14.5%All Others 87 57 30 F 52.4% 180 111 70 F 62.9%Total Elective WIES 1,558 1,613 (55) U -3.4% 2,915 3,075 (160) U -5.2%

This Year Last Year Variance Variance This Year Last Year Variance Variance % %

ED Discharges 10,275 9,890 385 F 3.7% 20,549 19,770 779 F 3.8%Acute Discharges 7,790 7,298 492 F 6.3% 15,603 14,744 859 F 5.5%Elective Discharges 1,566 1,556 10 F 0.6% 2,917 3,036 (119) U -4.1%Births 604 638 (34) U -5.6% 1,258 1,257 1 F 0.1%

Month

Month

Year to Date

Year to DateOther Volumes (compared to previous year)

Volumes August 2017

027


Revenue

Overall, revenue is $738k unfavourable for the month and $1.3M unfavourable YTD, reflecting the following:

• Under delivery of the YTD elective programme partly due to higher than contracted acute volumes through the winter months, $910k.

• MoH revenue adjustment offset by personnel costs charged to MoH, $687k. • Lower than anticipated retail sales in Retail Pharmacy $560k, offset by a reduction in cost of

goods sold (Other Expenses) of the same. • Reduction in donation revenue $256k. • ACC arrears initiative has softened the impact of the above YTD variances, $1.1M YTD

favourable. Expenditure

Overall operational expenditure is $816k favourable for the month and $1.6M favourable YTD. Net Personnel Costs - $339k favourable for the month, favourable $860k YTD

The overall favourable variance in personnel costs reflect vacancies across the services (part offset by outsourcing) as well as the delay in approving new roles pending confirmation of the 2017/2018 budget. These roles are now being actively recruited to. Overall FTEs are 80FTE favourable to budget (including outsourced personnel).

• Net Medical staff costs are $706k favourable YTD, 16FTE ($339k favourable for August), reflecting vacancies across the services in difficult to recruit to positions and the delay in approval of new roles mainly in Anaesthesiology, Radiology and Mental Health. These vacancies are currently being actively recruited to.

• Net nursing staff costs are $693k unfavourable YTD, (60) FTE ($187k unfavourable for August), reflecting the significant increase in clinical demand during July and August (winter peak). Nursing FTE, including the use of internal and external bureau is over consensus by 60 FTE YTD.

• Net Allied Health staff costs are $461k favourable YTD, 45FTE ($231k favourable for August) representing vacancies across the services that are being actively recruited to, mainly Anaesthetic Technicians, Social Workers, Psychologists and Occupational Therapists.

• Net support personnel are $93k favourable YTD, 27 FTE ($79k favourable for August); Vacancies in engineering, sterile supply, cleaners and hotel services, are partially offset by overspends in security and interpreters. Work continues with Human Resources to address the excessive overtime, annual leave and sick leave taken in Security Services. Implementation of new rosters to make annual leave and cover transparent as well as reviews to address the disproportionate sick leave have commenced.

• Net management and administration personnel are $293k favourable YTD, 52FTE ($106k favourable for August), reflecting vacancies across all areas.

Actual Budget Variance Actual Budget Variance Actual Budget VarianceMedical Personnel 17,578 17,688 110 F 33,357 34,062 706 F 848 864 16 FNursing Personnel 19,805 19,619 (187) U 38,934 38,241 (693) U 2,872 2,812 (60) UAllied Health Personnel 6,883 7,113 231 F 13,477 13,938 461 F 1,130 1,175 45 FSupport Personnel 2,451 2,530 79 F 4,716 4,809 93 F 510 537 27 FManagement Personnel 6,194 6,300 106 F 11,926 12,219 293 F 991 1,043 52 FTotals 52,911 53,250 339 F 102,409 103,269 860 F 6,352 6,432 80 F

Year to Date FTE

Personnel by Professional Group - Permanent and Outsourced

Month $$$ Year to Date $$$

028


Non-Staff Costs

• Clinical Outsourcing costs are $159k favourable YTD ($87k unfavourable for August), reflecting timing of Pacific contracts $206k that is part offset by an increase in the volume of elective work outsourced to private contractors $(47k), to mitigate impact from acute demand, the principal services being Orthopaedics, Ophthalmology, and General Surgery.

• Clinical Supplies costs are $412k favourable YTD ($435k favourable for August), reflecting a favourable movement in creditors relating to a year-end accrual, part offset by the high clinical demand over July and August (winter peak) and savings.

• Other expenses are $233k favourable YTD ($117k favourable for August) driven by favourable variances in retail cost of goods sold (offset by revenue), bad debts (offset by non-resident revenue) and conference costs. Unfavourable costs that offset include facilities unavoidable seismic and cladding assessment, fire safety compliance work, phasing of utilities and higher patient meals due to winter volumes.

• Interest, Depreciation and Capital Charge costs are $80k favourable YTD ($12k unfavourable for August) reflecting a delay for planned capital expenditure.

Looking Ahead

Whole of system work to confirm existing capacity within Counties Manukau Health is underway to identify our investment needs in the next 1-5 years that will contribute to the Regional LTIP plan. Forward planning for next winter has commenced together with an urgent assessment regarding the additional clinical capacity required. This will draw from, and feed into, the Northern Regional LTIP body of work.

029


Emergency Department, Medicine and Integrated Care Glossary

APAC Acute Post Acute Care DNA Did Not Attend ED Emergency Department FCT Faster Cancer Treatment MoH Ministry of Health MSC Manukau SuperClinic NBSP National Bowel Screening Programme NFD Nurse Facilitated Discharge NRA Northern Regional Alliance RMO Resident Medical Officer SMO Senior Medical Officer STEMI-PCI ST-elevation Myocardial Infarction Percutaneous Coronary Intervention YTD Year to Date Service Overview

The Emergency Department, Medicine and Integrated Care division is managed by Brad Healey (General Manager) with Clinical Directors/Heads Dr Carl Eagleton (Medicine), Dr Jeremy Dryden (Emergency Department), Dr Sally Urry (BreastScreen), and Clinical Nurse Directors To’a Fereti and Annie Fogarty. Report back on actions assigned during previous Hospital Advisory Committee meetings

National Bowel Screening Programme – regular update for the Hospital Advisory Committee

The Committee asked for a “Bowel Screening Programme regular update via the Medicine report each meeting” to be provided. We continue to meet with MoH to discuss implementation planning and funding issues. MoH has endorsed the service model we put forward. We have agreed with MoH to further refine our financial modelling to recognise a number of changes in financial modelling assumptions. At this stage it would appear that funding will be adequate for the first two years of the programme but there may be challenges from year three onwards. We have suggested to MoH that they consider reviewing funding levels at the end of years one and two in order to provide a more informed picture for year three and for recognising there is a high degree of sensitivity with the modelling assumptions, particularly around volume estimates. Highlights

Nurse Facilitated Discharges in General Medicine

NFDs have continued to increase over the past six months. August saw a record number of NFDs achieved since their implementation. This improvement has resulted from better identification of patients and improved engagement from medical teams. A 3.00pm weekday round with the General Medicine Flow Coordinator, Clinical Head of General Medicine, APAC nurse, and Middlemore Central Duty Manager occurs to identify potential discharges for the following day so that discharges can be moved out as early as possible the next morning. There were 199 NFDs in August with 26% of these during the weekends. NFDs have been a significant contributor to the early discharge of patients which has been improving for general medicine and this has improved patient flow.

030


General Medicine – Discharges since August 2015:

Cardiac CathLab Business Case

We have prepared a business case to establish a second cardiac cathlab at Middlemore Hospital. This work has been done in conjunction with the Northern Region Cardiac Network and NRA. The business case was endorsed by the Norther Region Cardiac Network at the meeting on 11 September 2017 and will continue to proceed through the CM Health and regional approval process. Winter demand update

Emergency Department

During August ED presentations totalled 10,285 which is a 3.4% increase over last year’s volumes for the same month. Year-to-date (YTD) presentations are 30,914 which represent a 5.5% increase from YTD last year. The daily average number of patients coming through the ED in August was 331 compared with 320 for the same month last year. Average daily ED presentations:

031


The ED continues to hold high volumes of patients through the day with an average of 26 patients waiting for beds at 7am (compared with an average of 37 in July); the highest volume in August being 57 waiting for beds at 07:00am. This means that ED continues to hold a ward full of patients every morning and through the day which results in the need for higher staffing levels to manage the clinical workload. As a result of demand pressures, the ED has been unable to meet the six hour target achieving 89% for August against a target of 95%. The graph below shows daily performance against this target. Daily ED performance against the six hour target – June 2017:

General Medicine

August was a busy month for inpatient services. Bed occupancy in General Medicine continues to be high at an average of 119% which presents significant challenges in managing patient flow through the hospital. Ward 34E has been open to medical patients as part of the winter capacity plan to provide this additional capacity. Roster changes for SMOs and the model of care changes are being developed to meet this escalating demand. We are also progressing an organisation wide program to improve patient flow. Volumes continue to be high and are likely to remain at this level for another month, putting significant burden on general medicine service delivery and staff To support the teams with admitting demand, volunteers amongst the General Medicine SMOs have been allocated to the ED for evening shifts seven days a week; this has reduced the number of call-outs for the B call consultant. However, given this is voluntary the additional shifts are not sustainable, and consequently a locum SMO has been secured for three weeks in September to resource the evening ED sessions in a more sustainable way. Adding to the current winter burden of demand on the General Medicine teams is high sick leave towards the end of August.

032


Update on previously reported issues

Issue Date reported Update

Gastroenterology – challenge of maintaining FCT and Ministry of Health targets

19 Oct 2016 Levels of demand continue to be less than earlier in the year; however they are still higher than previously forecast and there continues to be a high volume of acutes impacting on elective volumes. This results in cancellation of some elective procedures. Work continues to try and increase capacity within the Gastro dept. and meet targets. Due to the increased demand and previous SMO leave the colonoscopy waiting list is now up to 663 as at 31 August. This is 313 more than the ideal waiting list of 350 which is the number that enables targets to be achieved and maintained. The gastroscopy waitlist has increased to 1008 in August from 996 the previous month, with the ideal, for management purposes, 400. We continue to recruit for a fellow and have a candidate to start in December this year. We have also increased the in-house capacity with more SMOs agreeing to do additional lists. We continue to negotiate with SMOs to re-commence Saturday lists as several have expressed an interest in these. We’re also looking at further outsourcing of 350 colonoscopies in order to remove the backlog and enable targets to be achieved. We have also negotiated with the MoH NBSP for an extension on the date for achieving the targets and still receive the additional funding for reducing colonoscopy waiting lists.

Lung Function Lab Accreditation

31 May 2017 Alternative options to the MSC Lab redevelopment are now being explored.

033


Trend Rating Commentary (by exception)FY17-18 Aug-17 Target Var Actual Target Var

Total Caseweight 2,777 2,818 -1.5% 5,505 5,525 -0.4%Elective Caseweight 110 83 32.5% 166 155 7.1%Acute Caseweight (includes Intensive Care Unit) 2,667 2,735 -2.5% 5,339 5,371 -0.6%Outpatient First Specialist Assessment (FSA) Volumes 1,525 1,554 -1.9% 2,718 2,753 -1.3% Slightly lower General Medicine & Dermatology FSAsOutpatient Follow Up Volumes 3,874 3,898 -0.6% 7,136 7,082 0.8%Virtual First Specialist Assessments (FSAs) 193 195 -1.0% 344 373 -7.8%

Trend Rating Commentary (by exception)FY17-18 Jul-17 Target Var Actual Target Var

% Staff with Annual Leave > 2 years 8.5% 5.0% -3.5% 7.5% 5.0% -2.5%% Staff Turnover 10.2% 10.0% -0.2% 10.4% 10.0% -0.4%% Sick Leave 3.3% 2.8% -0.5% 2.9% 2.8% -0.1%Workplace Injury per 1,000,000 hours 0.0 10.5 10.5 14.7 10.5 -4.2


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


% Radiotherapy commences in 4 weeks 100% 100% 0% 100% 100% 0%% Chemotherapy commences in 4 weeks 100% 100% 0% 100% 100% 0%

% of patients admitted, discharged, transferred from ED within 6 hrs 89% 95% -6% 92% 95% -3%Continued high occupancy of hospital and presentation volumes into ED - unable to achieve 95%. There has been a 3.4% increasein presentations from August 2016

P1 (urgent) % diagnostic colonoscopy patients receive the procedure within 14 days 100% 85% 15% 98% 85% 13%

P2 (routine)% diagnostic colonoscopy patients receive the procedure within 42 days 68% 70% -2% 64% 70% -6%

P2 target continues to not be achieved due to the reduced capacity for the last 9 months. We now have a backlog of 350 colonoscopies and 45 gastroscopies to deal with in order to get the waiting lists back on track. Discussions on further outsourcing are now underway as well as discussions with the MoH on extending the target achievement deadline in order to be able to access the colonoscopy funding.

% surveillance colonoscopy patients receive their procedure within 84 days of planned date

98% 70% 28% 98% 70% 28%

% cardiac STEMI - PCI (angiography) within 120 mins - Northern Region Target 89% 80% 9% 85% 80% 5%

% Coronary Angiography within 90days (1 month in arrears) 85% 95% -10% 87% 95% -8%Very high acute demand across coronary intervention and Pacemaker insertions reducing ability to perform elective cases given the single Cath Lab

Medical Assessment – Triage 3-5 patients seen within 60 minutes 90 60 30 100 60 40Reflects activity in General Medicine and Medical Assessment

Door to Cathlab suspected Acute Coronary Syndrome < 3 days (median time) 69% 70% -1% 70% 70% 0%The need to juggle acute and elective requests is challenging our ability to meet targets

EMERGENCY DEPARTMENT, MEDICINE AND INTEGRATED CARE SCORECARD August 2017En

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General Medicine - Seen By Time (minutes)1st Time to be seen Triage 1 & 2 patients (median time in minutes) 34 30 -4 32 30 2

1st Time to be seen Triage 3 - 5 patients (median time in minutes) 83 60 -23 86 60 -26Due to presentation and surge ED aren't always able to see 3-5 triage categories in timeframe required.

2nd Time to be seen Triage 1 & 2 patients (median time in minutes) 57 30 -27 60 30 -30 Reflect referral TBS by specialists

2nd Time to be seen Triage 3-5 patients (median time in minutes) 77 60 -17 78 60 -18 Reflect referral TBS by specialists

FCT - % high suspicion first cancer treatment within 62 days - MOH Health Target 82% 90% -8% 78% 90% -12%

Analysis of breaches undertaken with tumour streams and actions developed to minimise or eliminate capacity breaches. Tumour streams are undertaking a review of services to identify gaps and develop action plans to address areas requiring further development. Service Managers attending weekly FCT operations group meeting to report on their tumour stream activity and areas for escalation and further discussion. Fortnightly governance group meeting and daptiv reporting in place.

FCT - %confirmed diagnosis first cancer treatment within 31 days 92% 85% 7% 93% 85% 8%


Average Length of Stay - Acute 3.7 3.5 -0.2 3.5 3.5 0.0Acute Readmissions within 28 days - Total 9% 10% -9% 10% 10% 3%Acute Readmissions within 28 days - 75+ 8% 10% 3% 10% 10% 4%

% of patients on home wards in General Medicine 31% 75% -44% 31% 75% -44%

Higher than expected volumes with high occupancy meant patients had to be placed in outlier wards. A small change is currently being trialled to outlier patients in specific areas per team so that we can minimise the impact on teams and wards

% of Outliers on non-medicine wards 18.0% 0.0% -18.0% 18.0% 0.0% -18.0%

Currently this is not possible to achieve as occupancy is higher than the capacity for General Medicine wards therefore 0 outliers are unable to be achieved. These are however minimised where possible.


% Discharges from transit lounge or home by 1100hrs 21% 30% 10% 21% 30% -9%

The discharge by 11 am is sustained at 20%. NFDs and other systems to enable earlier decision making continues. Medical roster change is also been awaited to see if this will result in any further improvement

% Discharged from Medical Assessment Unit by 1100hrs 37% 40% -3% 36% 40% -4%Model of care is currently being evaluated by a project team to see how improvements can be made in overall service delivery in Medical Assessment

% of patients < 28 hrs discharged from inpatient wards 8% 10% -2% 8% 10% 2%Implement Home First Renal policy - (increase Continuous Ambulatory Peritoneal & HD rate)

43% 50% -7% 42% 50% -8% Ratio of home therapies: total dialysis decreased slightly from 43.6%:50% to 43%:50% in August. There is 1 less patient on home therapies overall- with this patient from PD receiving a transplant. There were 3 transplants in total for August and 2 patients on the ADAPT programme f t PD

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% Women with Breastscreen in last 24 months - total 2766 2400 366 70% 70% 0%% Women with Breastscreen in last 24 months - Maaori 344 289 55 66% 70% -4%% Women with Breastscreen in last 24 months - Pacific 430 377 53 77% 70% 7%

The service continues to work on Maaori coverage through following up DNR women and GP data matching. Maaori coverage has increased by 2% since Jan this year

Equi

tyVolumes Screened % Screened in last 24 Months

036


Surgery, Anaesthesia and Perioperative Services Glossary

ACC Accident Compensation Corporation CLAB Central Line Associated Bacteraemia DOS Day of Surgery DNA Did Not Attend ESPI Elective Services Patient Flow Indicator FSA First Specialist Assessment GP General Practitioner/General Practice LOS Length of Stay MMH Middlemore Hospital MSC Manukau SuperClinic VTE Venous Thromboembolism YTD Year to Date Service Overview

Surgery, Anaesthesia, and Perioperative Services is managed by Mary Burr (General Manager), with Dr Mark Moores (Clinical Director – Surgery, Anaesthesia and Perioperative Services), Dr Tony Williams (Clinical Director - Critical Care Complex), Jacqui Wynne-Jones (Clinical Nurse Director – Surgery, Anaesthesia and Perioperative Services), and Annie Fogarty (Clinical Nurse Director – Acute and Critical Care Complex). Highlights

Volumes

Total surgical patients treated and discharged at CM Health facilities were 3162 compared with a contract of 2932 and 2919 in the previous year. This will establish a good buffer for us going forward. Hip and Knee target outputs for August are 72 against target of 73 (YTD 156/139) and cataracts outputs are at 135 (YTD target 273/219). Safety

No patient falls with harm or CLAB infections were recorded for August 2017 (both result in patient harm and high cost of care if they occur). Revenue

Overall revenue for the month was higher than budget by $186k (YTD $127k). This is mainly due to $53k in acute Tahitian Burns Revenue, recovery of nursing cost from Anaesthetic Research fund $64K, and urology revenue being in excess of accrual $51k. ACC elective revenue was $47k higher than budget due to a strong focus on this target. Acute Theatre Performance

Acute outputs remain consistently high month on month, with 129,205 acute minutes delivered in August.

037




Critical Care beds under increasing demand

27 Jul 2016 August admissions for Critical Care Complex sit at 149 which is manageable and within capacity. There were 20 paediatric admissions.

Demand on Ophthalmology and Otorhinolaryngology (ORL) services

27 Jul 2016 Good progress continues. Overdue follow ups have improved by 586 in August. Advanced Practitioner Optometrists are working alongside Ophthalmologists and have made very good strides with Glaucoma patients. The new outpatient facility with 5 clinic rooms at MMH is working well.

Potential machinery failure in the MSC Sterile Supply Unit

8 Mar 2017 The MSC Sterile Supply Unit is at risk of failure due to ageing machinery. Remedial work is planned for January 2018. There is a plan in place to manage failures should they occur before the planned works.

High acute demand 23 Aug 2017 Acute demand has been more manageable this month. We have also introduced a new coordinator role which is having a positive effect on management of the acute volume.

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Total Caseweight (Provider view) 3,421 3,290 4.0% 6,582 6,475 1.7%

Elective Caseweight 1,352 1,383 -2.2% 2,597 2,638 -1.6%Complexity has reduced slightly . We expect to catch up in Sep 17.

Acute Caseweight 2,069 1,908 8.5% 3,985 3,837 3.9%Acute discharges 1,891 1,668 13.3% 3,416 3,356 1.8%Elective Surgical Discharges 1,363 1,350 0.9% 2,584 2,578 0.3%Virtual FSAs/Follow ups -(GP consult and nonpatient appointments) 144 132 9.1% 301 264 14.0%Personnel Costs ($000) $13,207 $13,415 1.5% $25,493 $26,117 2.4%Financial Result Total ($m) $15,872 $15,861 -0.1% $30,437 $30,884 1.4%

Reduce clinical outsourcing ($000) $519 $414 -25.3% $889 $865 -2.7%Procedures below budget but mix weighted towards ORTHO and GENSURG means that $ are over budget- will remedy in Sep 17.


% Staff with Annual Leave > 2 years 15.9% 5.0% -10.9% 15.3% 5.0% -10.3%Current project underway to reduce this liability. Working service by service.

% Staff Turnover 9.1% 10.0% 0.9% 9.7% 10.0% 0.3%% Sick Leave 2.5% 2.8% 0.3% 2.5% 2.8% 0.3%Workplace Injury per 1,000,000 hours 5.7 10.5 4.8 10.21 10.5 0.3


Hand Hygiene compliance rate (based on Gold Audit) - Ward 11 70% 80% -9.8% 70% 80% -9.8%Two gold auditors trained on Ward 11. New staff are receiving one to one training from CSN. Hand Hygiene is the focus topic on the ward in October 17.

Pressure Injuries / 100 patients 0.00 0.00 0.00 0.00 0.00 0.00Falls causing major harm / 1000 bed days 0.00 0.00 0.00 0.00 0.00 0.00Severe Pressure Injury (ungradeable) per 1000 bed days 0.00 0.00 0.00 0.00 0.00 0.00CLAB rate/ 1000 line days 0.0 0.0 0.0 0.0 0.0 0.0

VTE - Ortho (Acute and Elective) 5.0 2.0 -3.0 9.0 0.0 -9.0Each case is reviewed by VTE committee . High orthpaedic demand noted.


Pre-operative Length of Stay Days (from admit to surgery) 1.2 1.0 -0.2 1.2 1.0 -0.2 We have a number of projects working to reduce preop LOS e.g. under VDO outcomes will be reported through those mechanisms.

ESPI 2 No. patients waiting >120 days for FSA - Elective (Surgical Services incl Gynae)

16 0 -16.0 16 0 -16.0 Process in place to recovery ESPI2 by end of Sep 2017.

ESPI 5 No. patients waiting >120 days Treatment - Elective (Surgical Services incl Gynae)

14 0 -14.0 14 0 -14.0This represents a good recovery from a red ESPI in July 2017.

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Average Length of Stay - Acute Inpatient incl Burns 4.00 3.8 -0.2 3.96 3.8 -0.2Average Length of Stay - Acute Inpatient excl: Burns 3.95 3.8 -0.2 3.92 3.8 -0.1Average Length of Stay - Acute Inpatient excl: Burns and Spinal Ortho 3.94 3.8 -0.1 3.88 3.8 -0.1Average Length of Stay - Electives 1.13 1.5 0.4 1.11 1.5 0.4


Theatre list utilisation - % used MMH/MSC 82% 85% -3% 76% 85% -9% Theatre utilisation is climbing back towards 82%Theatre session utilisation - % used MMH/MSC 97% 95% 2% 95% 95% 0%Elective Theatre turnaround times- Mins (MSC only) 15 15 0 15 15 0Elective cancellations - Day of surgery as % of all Elective (all reasons)- SAPS only

9% 5% -4% 10% 5% -5%

Day of Surgery Admissions (DOSA) 93% 90% 3% 93% 90% 3%Day Case Rate (Elective/ Arranged) -Subspecialties in SAPS only Adults/kids 64% 65% -1% 65% 65% 0%MMH % patients discharged to discharge lounge or home by 1100hrs 29% 30% -2% 27% 30% -3%MMH % patients discharged to discharge lounge or home by 1100hrs -GEN SURG 34% 30% 4% 31% 30% 0.6%

MMH % patients discharged to discharge lounge or home by 1100hrs- ORTHO 24% 30% -7% 23% 30% -7%MMH % patients discharged to discharge lounge or home by 1100hrs- PLASTICS 24% 30% -6% 26% 30% -4%Ratio FSA/FU clinic ratio 35% 31% 4% 36% 31% 5%Outpatient DNA rates - overall- Surgical Services only 8% 10% 1.7% 8% 10% 1.8%Outpatient DNA rates - Maori (FSA) - Surgical Services only 16% 10% -5.6% 15% 10% -4.8%Outpatient DNA rates - Pacific (FSA)- Surgical Services only 14% 10% -4.2% 13% 10% -2.9%


% of hospitalised smokers receiving smokefree advice & support -Total (Surgical)

94% 95% -1% 94% 95% -1%Continuing to monitor and feedback to services who are not at 100%.


Patient Experience Survey - month (n=91) and YTD (n=91) 91% 90% 1% 83% 90% -7% Excellent result for this month

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YTD targets are looking. Slight increase during August 2017. Pressure has reduced during Sept 2017 so will recover in the coming month.

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DOS cancellations continue to be higher than we would like. Is a focus for our dashboard within the Opt Theatre Project and our new data cube process.

Great improvement in discharges before 11am across services. We continue to monitor and improve those below 30%.

DNA for Maori and Pacific requires and organsational approach.

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040


Central Clinical Services Glossary

CSF Cerebrospinal Fluid CT Computed Tomography ED Emergency Department ESBL Extended-Spectrum Beta-Lactamases eMR Electronic Medication Reconciliation FNA Fine Needle Aspiration FTE Full Time Equivalent IANZ International Accreditation New Zealand MRI Magnetic Resonance Imaging MRT Medical Radiation Technologist PT/INR Prothrombin Time/International Normalised Ratio SMO Senior Medical Officer YTD Year to date Service OverviewThe Central Clinical Services division is managed by Ian Dodson (General Manager), with Clinical Directors/Heads Dr Ross Boswell (Laboratory), Dr Sally Urry (Radiology), Dr Mary Christie (Histopathology), and To’a Fereti (Clinical Nurse Director).

Highlights

Radiology

The new Team Leader for Sonography has been recruited, and will commence work on 16 October 2017. Advertising in the United Kingdom for MRTs has resulted in us recruiting three MRTs, and a further two have been offered contracts (to date) and whom we hope will accept. Graduating students will be interviewed next week with the expectation that we will recruit six of them. The remote workstation for plain film reporting that was installed has been very successful. The number of plain films unreported has reduced markedly, with the radiology SMOs putting in a huge effort as well. The number of unread non-urgent plain films has reduced from 4000 to 1907 in the past month and is expected to continue to reduce in the next month. Laboratory

A major change to the structure of the Lab Information System to enable efficient operation when/if electronic orders are fully implemented occurred uneventfully mid-August. The smooth transition was a result of several weeks testing and careful planning. Update on previously reported issues


Reduced Radiologist FTE

7 Sep 2016 Current FTE (as at end of August) is 4.48 down, (5.68 in previous month) below budgeted FTE. The vacancy rate is 12%. The vacancy rate will increase up until the end of the year before an expected return to full staffing in the first quarter of 2018. We have two staff returning from parental leave, and two going on leave. We are working hard on recruiting to fill vacancies.

041


General x-ray service 7 Sep 2016 The general x-ray service continues to be extremely busy with inpatient/ED and general practice patients. The shortage of MRTs is being ameliorated by MRI techs assisting as general MRTs. Plans put in place over the last two months have substantially improved the throughput of the x-ray service.

Histopathology Lab 8 Mar 2017 The Business Case to relocate the Histopathology Lab to relieve the accommodation issues is pending submission to the Board depending on the outcome of the Galbraith seismic review. With the potential for further delays further short-term options are being investigated to keep a safe space in the laboratory. Monthly updates continue to be provided to IANZ.

Rapid reduction in MRT workforce

31 May 2017 There has been a further increase in the MRT vacancies for reasons previously reported. International recruitment has resulted in at least three appointments and more to come. Existing staff are covering vacant shifts to ensure the service is maintained however this is becoming increasingly more problematic with the sustained shortage in FTE. The radiology department have been working with the staff and the union to ensure safe staffing and that workloads are appropriate. The MRT FTE shortage will substantially improve in November/December with new staff arriving from overseas and a significant cohort of new graduates coming on board as part of the annual new graduate intake.

042

Counties Manukau District Health Board – Hospital Advisory Committee Agenda 4 October 2017


% Staff with Annual Leave > 2 years 10.3% 5.0% -5.3% 8.6% 5.0% -3.6%Significant planning has been put in place in Labs to reduce high numbers of outstanding annual leave. It is expected that high annual leave balances will reduce steadily over the next few months

% Staff Turnover 2.4% 10.0% 7.6% 1.9% 10.0% 8.1%


% electronic medication reconciliation completed for high risk patients within 48hrs

79% 80% -1% 68% 80% -12%

Improvement in eMR rates sustained for the last 2 months. Further changes are currently being tested with weekend trial service to see if rates can exceed 80%


% MRI scans completed within 6 weeks from acceptance of referral 70% 85% -15% 74% 85% -11%High demand continues and outstrips our capacity Outsourcingincreased slightly. MRT staffing issues affecting MRI delivery slightly.

% CT scans completed within 6 weeks from acceptance of referral 93% 95% -2% 95% 95% 0% 2% under, CT staffing have been assisting with MRT staffing shortages.

Radiology - Inpatient radiology times < 24hours 92% 95% -3% 93% 95% -2%3% under, delays due to staffing issues. Will be remedied by Nov/Dec

Radiology ED radiology times < 2 hours 94% 95% -1% 94% 95% -1%1% under target, will be remedied when staffing is increased in Nov/Dec

Laboratory -Test turnaround time (TAT) within 60minsPotassium 98% 90% 8% 99% 90% 9%Haemoglobin 99% 98% 1% 99% 98% 1%PT/INR 97% 98% -1% 98% 98% 0%Troponin 1 for ED 90% 90% 0% 93% 90% 3%

Histology - All - 5 working days 88% 90% -2% 91% 90% 1%Breast - 3 working days 96% 80% 16% 97% 80% 17%Non gynae FNAs - 3 working days 91% 90% 1% 92% 90% 2%

Blood Bank - antibody screen within 4 hours 95% 90% 5% 96% 90% 6%Microbiology

CSF cell count <30mins 97% 90% 7% 97% 90% 7%ESBL screens <2days 94% 95% -1% 95% 95% 0%CDT (C. diff Toxin) <25hrs 97% 90% 7% 95% 90% 5%UCHM (Urine Chemistry) <60mins 96% 90% 6% 95% 90% 5%

% radiology results reported within 24 hours 39% 75% -36% 47% 75% -28%

Work station sent to external locum for reporting has had a major effect, will show in September stats. We have also postponed an education session for SMOs to run a catch up session on reporting. GP referrals are being diverted to community providers where posible to reduce hospital volumes.


% transcribed clinical summaries (meddocs) authorised <7 days of creation 70% 95% -25% 70% 95% -25%Routine follow ups continue with clinicians and clinical teams that are breaching this target. Escalation to clinical leads of the appropriate areas continue to keep the authorisation rates up

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CENTRAL CLINICAL SERVICES SCORECARD August 2017En

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043


Kidz First and Women’s Health Glossary

ALOS Average Length of Stay CLAB Central Line Associated Bacteraemia DNA Did Not Attend ED Emergency Department FTE Full Time Equivalent FSA First Specialist Assessment HCA Health Care Assistant HWNZ Health Workforce New Zealand LMC Lead Maternity Carer LTIP Long Term Investment Planning MCIS Maternity Clinical Information System MDES Midwifery Development and Education Services MERAS Midwifery Employee Representation and Advisory Services MoH Ministry of Health NNU Neonatal Unit NSU Newborn Screening Unit NZNO New Zealand Nurses Organisation RN Registered Nurse WIES Weighted Inlier Equivalent Separations YTD Year to date Service Overview

Kidz First and Women’s Health is managed by Nettie Knetsch (General Manager) with Dr Wendy Walker (Clinical Director Kidz First), Dr Sarah Tout (Clinical Director Women’s Health), Thelma Thompson (Director Midwifery), and Michelle Nicholson-Burr (Clinical Nurse Director). Highlights

Activity summary

For August 2017, discharges in Kidz First Medical were up by 60 on the previous August. ED presentations were also up by 279 for the month when compared to August last year. In summary, the first two months of winter 2017/18 have seen 352 more ED presentations and 34 more discharges compared to the same period last year. Inpatient patterns have been different from other years with greater variations between weeks resulting in challenges with rostering the right resources at the right time. Early September has seen another spike in inpatient volumes but this has since slowed down again. Neonatal Unit

Discharges from the Neonatal Unit are up by ten babies YTD August 2017 and the WIES is up by seven YTD reflecting the sudden decrease in overall admissions from the last week in July and throughout August. Occupancy for August was 62% (based on resourced 28 cots). The Unit was able to increase annual leave for staff who have been very busy after sustained high occupancy levels over the last nine months. Acuity remained high in the unit with most days the unit had more level three babies than level two babies.

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Births

There were 545 births at Middlemore Hospital and 59 at the three community units; a total of 604 births for the month, which is 34 births less than August 2016. YTD the variance is just one birth, however, the distribution of the births continues to see a further decrease of 36 in the Primary Birthing Units (YTD 129 across the three units) and 37 more births at Middlemore. However, occupancy for postnatal stay at the Primary Birthing Units remains around 85% reflecting the utilisation of the Units for women transferring from Middlemore after birth to the units. Annual reporting

The Women’s Health and Newborn Annual Report 2016-2017 was endorsed by the Executive Leadership Team in August and then submitted to the Ministry of HEalth on 1 September 2017. The presentation of the report to the organisation will be on Wednesday 20 September. In addition to the Maternity outcomes and projects, the 2016-2017 report includes chapters on Newborn (Neonatal) as well as Gynaecology projects and outcomes. Newborn Screening Unit

Feedback on the NSU for CM Health’s Universal Newborn Hearing Screening and Early Intervention Programme (UNHSEIP) desktop audit has now been received. Significant improvements during 2016/17 have been endorsed by the NSU such as decreasing wait-times for infants for Audiology Assessment, and the high screening completion rates in order to meet one, three, and six month national UNHSEIP goal targets. The auditors have remarked positively on our progress with only one outstanding action regarding Audiology which we will achieve by the end of this year. Emerging Issues

Staff sick leave

Staff sickness across both Kidz First and Women’s Health remained high in August, with a lot of vaccinated staff still off with influenza like illness. MCIS Update

Ministry of Health

• Detailed information has now been received on MoH timeframe and road-map for development of the MCIS.

• MoH is in the process of setting up the new Governance, Steering, and Clinical Advisory Groups. Some of our clinical staff have already been approached to be members on these new groups which we have endorsed.

• With the MMPO (national midwifery and maternity provider organisation) rolling out the MMPO part of the MCIS for self- employed midwives, issues have arisen on data governance between LMC midwifery care and the DHB MCIS. An urgent meeting has been arranged for 4 September 2017 to work through this.

Local CM Health Development

• Letter of Agreement with Clevermed extended for three months (in absence of national contract) until 31 October 2017

• Two Clinical Midwife Specialists have been appointed to work with the current MCIS Midwife Specialist on the standardisation of work-flow processes and MCIS. They commenced in early August and have settled in well and commenced support and training for the MCIS standardisation work.

045


• The Community Midwifery services have already completed standardisation of MCIS for their large team and this will assist in the work required for the inpatient and acute settings as well.

• Following two multidisciplinary extended hybrid lab sessions during which very detailed scenarios were used to ascertain whether introducing more 'paper' (i.e. clinical notes) would make the care safer it was agreed that an extended hybrid in fact increased clinical risk further. The Steering Group has accepted this recommendation and communicated this with the wider maternity workforce on 18 August 2017.



Neonatal Unit capacity

Apr 2016 Occupancy for August decreased to 62%. Regional neonatal capacity report was finalised at the end of August for presentation to regional forums in September and to align with the regional LTIP work.

Caesarean Section Rate

8 Mar 2017 Caesarean Section (CS) rate for August YTD remained at 28%. The CS rate and processes are reviewed routinely with the clinical team. At the June regional Women’s Health meeting significant increases in CS rates were also reported from Auckland and Waitemata and the region will continue with data analysis and clinical discussion to understand what is driving the significant spike across the region over the past five months. Midwifery (both LMC and self-employed) and junior medical staff shortages may well be a factor in this increase as well as the impact of new practice guidelines. Ongoing local and regional review is in place.

Midwifery workforce

8 Mar 2017 Following on from the National Midwifery Advisory Group meeting reported on last month, a presentation of the midwifery workforce projections for the Auckland region by DHB took place on Friday 18 August. This provided the region with the most up to date projections for midwifery workforce requirements and provided a good framework for further planning. DHB Shared Services are now also linked in to this work. The projected numbers of midwives required will be huge and will require a new strategy for training and retaining midwifery workforce as well as looking at other workforces, models of care, and extending multidisciplinary teams (e.g. HCAs and the role of RNs in maternity services). The data presented by HWNZ at this meeting highlighted the specific Auckland issues but was not complete as yet as it had missed DHB employed community midwifery FTE. Feedback was provided and the Midwifery Strategic Advisory Group is finalising their work plan in September which will be signed off by HWNZ Board and then distributed to DHBs. In addition, the regional General Managers, Clinical Directors, and Directors of Midwifery continue to meet monthly to provide updates on the current regional midwifery shortages. Each DHB has different pressures, with Auckland DHB currently having the biggest employed midwifery shortfall and CM Health having shortages in the senior midwifery positions

046


as well as LMC shortages. The regional Directors of Midwifery are presenting to a regional NZ College of Midwives meeting on 5 September 2017 on the Auckland region midwifery workforce shortages and strategies. For CM Health, our new graduate cohort from May is settling in well. Two new graduate midwives started in August as well. The pressure area for the service currently is the Birthing and Assessment Unit where we have shortages as well as skill-mix issues with a cohort of experienced midwives having retired or going on parental leave. Birthing and Assessment are starting their workflow and process project with the assistance of Ko Awatea and following the principles of the Maternity Ward project (Living our Values). We have reinstated the provider Midwifery Strategic Staffing group with representation from both MERAS and NZNO to discuss local short term strategies and act on feedback and ideas from the midwifery workforce. These meetings occur monthly.

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Trend Rating Commentary (by exception)FY17-18^ Aug-17 Target Var Actual Target Var

Acute Caseweight - Gynaecology Inpatients- acute 150 128 17% 283 256 11% High acuityAcute Caseweight - Secondary Neonatal Womens health 98 133 -26% 290 265 9% Timing and coding issues

Acute Caseweight - Inpatient maternity care primary maternity facility 439 732 -40% 943 1464 -36%

Acute Caseweight - Women's Health secondary 604 612 -1% 1263 1167 8%Elective Caseweight - Gynaecology Inpatients - elective 108 148 -27% 202 282 -28% Theatre and Anaesthetics impactsHysteroscopy 9 23 -61% 29 44 -34%Total Discharges - Gynaecology Inpatients- acute 276 263 5% 511 517 -1% Small variancesTotal Discharges - Secondary Neonatal Womens health 151 153 -1% 344 314 10%Total Discharges - Inpatient maternity care primary maternity facility 319 328 -3% 679 642 6%Total Discharges - Women's Health secondary 1211 1174 3% 2491 2379 5%Total Discharges - Gynaecology Inpatients - elective 114 106 8% 205 240 -15%Gynaecology - 1st Attendance 257 276 -7% 499 527 -5% Offset by virtual FSANon-Contact FSA Gynae Virtual 51 45 13% 105 89 18%First Obstetric Consults S/B Doctors 273 297 -8% 519 568 -9%DHB non-specialist antenatal consults

1086 1488 -27% 2111 2977 -29%

Volumes similar to last year's actual non-resident chargeable and overseas eligible are not included. It takes 3 months for the eligibility status to be confirmed.

Gynaecology - Subsequent Attendance 336 285 18% 618 546 13% Increasing complexitySubsequent Obstetric Consults F/U S/B Doctors 284 276 3% 507 527 -4%DHB non-specialist postnatal consults 1150 1306 -12% 2,415 2612 -8%Budgeted FTEs 343 356 4% 350 356 2% Midwifery vacancies

Operating Costs ($000) $495 $468 -6% $980 $935 -5%

High bureau usage due to midwifery vacancies and sick leave and high clinical supply usage due to high c-section and inductions

Personnel Costs ($000) $3,016 $3,076 2% $5,760 $5,864 2% Midwifery vacancies

Financial Result Total ($000) -$3,429 -$3,476 1% -$6,591 -$6,799 3%High sick leave and high use of bureau staff due Midwifery vacancies

Reduce Clinical Outsourcing ($000) $12 $6 -100% $25 $6 -317%

High bureau usage due to midwifery vacancies and sick leave, MDES expenses offset against maternity review board funding

Trend Rating Commentary (by exception)FY17-18^ Jul-17 Target Var Actual Target Var

% Staff with Annual Leave > 2 years - (one month in arrear) 19.7% 5.0% -14.7% 20.7% 5.0% -15.7% Remaining midwifery vacancies% Staff Turnover - (one month in arrear) 11.7% 10.0% -1.7% 12.6% 10.0% -2.6%% Sick leave - (one month in arrears) 3.8% 2.8% -1.0% 3.2% 2.8% -0.4% Remains high in Jul/Aug 2017Workplace injuries recorded per 1,000,000 hours - (one months in arrears) 0.00 10.5 10.5 8.9 10.5 1.6

Timing issues - considering reporting one month in arears

WOMEN'S HEALTH SCORECARD August 2017En

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Emergency trolley checks (days checked) per month 81% 100% -19% N/A N/A N/A Does not include GCU and B&A

Hand hygiene (compliance with checks) per month 84% 80% 4% N/A N/A N/ADoes not include Botany, Pukekohe, Maternity North, Maternity South

Safe Sleep audits compliance 94% 100% -6% N/A N/A N/A Improving trendViolence Intervention Programme (VIP) Screening 57% 80% -23% N/A N/A N/A Challenges with staff sick leave


ED 6 hour target - National Health target (Gynae) 83% 95% -12% 75% 95% -20% Analysing daily reportsESPI 2 - No. waiting >4 months for FSA - Elective 0.0 0.0 0.0 2.0 0.0 2.0ESPI 5 - No. waiting > 4 months for treatment - Elective 2.0 0.0 2.0 22.0 0.0 22.0


ALOS Women's Health - babies (WNB and Neonates) 2.80 3.10 0.30 3.50 3.30 -0.20Average Length of Stay Gynaecology - Middlemore 1.56 1.45 -0.11 1.68 1.57 -0.11Average Length of Stay Gynaecology - MSC Inpatients 0.80 0.73 -0.07 0.85 0.70 -0.15Average Length of Stay Obstetric (DHB Mat) (1 month in arrear) 2.50 2.23 0.27 2.50 2.35 0.15Average Length of Stay Obstetric (Ind. Mat) (1 month in arrear) 2.22 2.27 -0.05 2.22 2.27 -0.05Average Length of Stay Vaginal Deliveries overall 2.25 2.69 -0.44 2.19 2.80 -0.61

Maaori - 1st time mothers 2.00 2.63 -0.63 2.91 2.54 0.37Pacific - 1st time mothers 3.22 2.54 0.68 3.05 2.75 0.30


FSA / Follow up ratio - Gynae 1:1.31 1:1.1 1:1.24 1:1DNA - Midwifery Antenatal clinics - First 16% 15% -1% 16% 14% -2%DNA - Midwifery Antenatal clinic - Follow up 14% 13% -1% 15% 13% -2%DNA - Doctor Antenatal clinics- FSA 14% 18% 4% 14% 13% -1%DNA - Doctor Antenatal clinics - Follow up 11% 9% -2% 12% 11% -1%

Trend Rating Commentary (by exception)FY17-18^ Aug-17 Target Var Actual YTD* Var

Outpatient DNA - Maaori (Gynae) 11% 11% 0% 12% 10% -2%Outpatient DNA - Pacific (Gynae) 8% 8% 0% 9% 10% 1%Outpatient DNA - Maaori (Obst) 23% 24% 1% 26% 10% -16%Outpatient DNA - Pacific (Obst) 18% 19% 1% 18% 10% -8%


Patient experience survey very good/excellent- month (n=24) and YTD (n=77) 96% 76% 20% 84% 76% 8%

NOTES^FY17-18 - fiscal year 2017 and fiscal year 2018

Monitoring DNA Rate

Small variances across ALOS measures

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Acute Caseweight - Paediatric Medicine Inpatients 325 414 -21% 688 807 -15%

Acute Caseweight - Emergency Medicine - ED 71 76 -7% 136 153 -11%Acute Caseweight - Inpatient Paediatric Intensive Care Unit 4 3 33% 6 5 20%Acute Caseweight -Secondary Neonatal Unit 119 161 -26% 328 321 2%Acute Caseweight - Paed Surg - accounted under Adult Surgery 139 139 0% 272 279 -3% Small varianceElective Caseweight - Paed Surg - accounted under Adult Surgery 91 90 1% 151 172 -12% Small varianceTotal Discharges - Paediatric Medicine Inpatients 570 511 12% 1143 1112 3% Increase on winter 2016Total Discharges - Emergency Medicine - ED 257 217 18% 517 498 4% Increase on winter 2016Total Discharges - Inpatient Paediatric Intensive Care Unit 3 4 -25% 7 6 17%Total Discharges - Secondary Neonatal Unit 30 26 15% 67 57 18% Small increase in discharges YTDTotal Discharges- Acute Paed Surg - accounted under Adult Surgery 177 145 22% 334 283 18% Very high volumes in AugustTotal Discharges- Elective Paed Surg - accounted under Adult Surgery 140 112 25% 249 237 5% Very high volumes in AugustED attendances 2497 2218 13% 4998 4646 8% August remains highPaed Medicine - 1st Attendance 229 222 3% 401 424 -5% Back on track for the monthNon-Contact FSA - Any Medical specialty 50 50 0% 99 96 3%Paed Medicine - Subsequent Attendance 396 352 13% 647 673 -4%

Budgeted FTEs 289 294 2% 289 294 2% Additional revenues and vacancies in neonatal unit

Operating Costs ($000) $374 $353 -6% $718 $705 -2%High clinical supply expenses both in community and inpatient

Personnel Costs ($000) $2,554 $2,656 4% $4,922 $5,074 3% Vacancies in neonatal unitFinancial Result Total ($000) -$2,646 -$2,821 6% -$5,077 -$5,403 6% Additional revenuesReduce Clinical Outsourcing ($000) $21 $7 -200% $22 $13 -69% Offset against revenues

Trend Rating Commentary (by exception)FY17-18^ Jul-17 Target Var Actual Target Var

% Staff with Annual Leave > 2 years 15.7% 5.0% -10.7% 18.5% 5.0% -13.5% Decreasing trend% Staff Turnover 8.3% 10.0% 1.7% 15.1% 10.0% -5.1% Decreasing trend% Sick leave 3.0% 2.8% -0.2% 3.2% 2.8% -0.4% Remains higher in August Workplace injuries recorded per 1,000,000 hours 0.0 10.5 10.5 4.4 10.5 6.2


Neonatal Rate of medication errors/1000 bed days per month 5.4% 3.2% -2.2% 5.2% 3.2% -2.0% Small variance Neonatal Care CLAB rate per 1000 line days per month 0.0 0.0 0.0 0.0 N/A N/ACLAB insertion bundle compliance - NNU 96% 100% -4% 95% 100% -5%CLAB prevention maintenance bundle compliance- NNU 89% 100% -11% 91% 100% -9%Emergency trolley checks (compliance with checking) 93% 100% -7% N/A N/A N/AHand hygiene (compliance with checking) 85% 80% 5% N/A N/A N/AViolence Intervention Programme (VIP) Screening 70% 80% -10% N/A N/A N/A

KIDZ FIRST SCORECARD August 2017En

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ED 6 hour target - National Health target (Kidz First ED) - Initial speciality 97% 95% 2% 97% 95% 2%ESPI 2 - No. waiting >4 months for FSA - Elective 0.0 0.0 0.0 0.0 0.0 0.0

Trend Rating Commentary (by exception)FY17-18^ Aug-17 LY Act Var Actual YTD* Var

Admission Rate Babies in the first year of life (Total) 18% 23% 5% 21% 21% 0%Admission Rate Babies in the first year of life (Maaori) 25% 25% 0% 25% 25% 0%Admission Rate Babies in the first year of life (Pacific) 33% 30% -3% 27% 28% 1%

ALOS (raw)- Kidz First - Surgical - Surgical Floor 1.47 1.92 0.45 1.75 2.10 0.35ALOS (raw)- Kidz First Medicine - Kidz First Wards 3.04 2.96 -0.08 2.89 2.70 -0.19 Small variancesALOS (raw)- Kidz First Medicine - ED Short Stay (hrs) 4.63 4.35 -0.28 4.46 4.26 -0.20 Small variancesALOS (raw) - Kidz First - Neonatal 14.7 20.0 5.3 18.3 21.1 2.8 Reflecting lower - volumes and acuity


Outpatient DNA - FSA 8% 11% 3% 8% 10% 2%Outpatient DNA - Follow up 14% 10% -4% 15% 12% -3% Monitoring trend and process


Patient experience survey very good/excellent- month (n=1) and YTD (n=8) 100% 76% 24% 63% 76% -14%

NOTESLY Act - Last year actuals^FY17-18 - fiscal year 2017 and fiscal year 2018

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Adult Rehabilitation and Health of Older People Glossary

ACC Accident Compensation Corporation ACE Acute Care for the Elderly ASRU Auckland Spinal Rehabilitation Unit AT&R Assessment, Treatment and Rehabilitation CNM Charge Nurse Manager LOS Length of Stay MMH Middlemore Hospital MoH Ministry of Health YTD Year to date Service Overview

The Adult Rehabilitation and Health of Older People Division is managed by Dana Ralph-Smith (General Manager) with Dr Peter Gow (Clinical Director). Highlights

Physiotherapy Department

The Physiotherapy department received ‘fully attained’ ratings across all criteria as part of the ACC Surveillance Audit of Sector Standards. Several strengths of the department (which spans across Middlemore-based Acute Allied Health, Outpatient Allied Health services, Hand Therapy, and ASRU) were highlighted including ongoing initiatives and professional drive for continued development. The auditors noted the momentum of this drive was not top-down, rather initiated from the physiotherapists working in each department. Additionally, their ability to manage such a large and varied workload, while still maintaining client centred care and developing ongoing innovations was noted. Update on previously reported issues


Safe Moving and Manual Handling

12 July 2017 A joint teleconference was held with Waitemata and Counties Manukau DHBs, with subject matter expert Dr Mike Fray, regarding the use of a baseline assessment tool. Dr Fray will provide a proposal early September, which in turn will be included in a business case to the Executive Leadership Team.

System-wide (acute) demand 23 Aug 2017 Escalation plans have been wound down, and staff have contributed to a division-level “lessons learnt” report to inform Winter Planning for future years.

052



Spinal Inpatient ACC Revenue ('000s) $662 $659 0.5% $1,287 $1,358 -5.3% Delay in invoicing due to pending contractsNon-acute Rehabilitation ACC Revenue ('000s) $783 $488 60.4% $1,481 $977 51.6%

Budgeted FTEs 509 481 -5.9% 507 481 -5.4%

being opened in Wards 24 and 31 due to demand requirements

Operating Costs ($000) $4,256 $4,149 -2.6% $8,425 $8,293 -1.6%

Personnel Costs ($000) $3,231 $3,295 2.0% $6,372 $6,591 3.3%Financial Result Total ($000) $3,644 $3,569 -2.1% $6,950 $7,091 2.0%Reduce clinical outsourcing ($000) $277 $302 8.1% $577 $603 4.4%


% Staff with Annual Leave > 2 years (1) 4.1% 5.0% 0.9% 4.2% 5.0% 0.8%% Staff Turnover (2) 11.8% 10.0% -1.8% 15.0% 10.0% -5.0% Resignations due to individuals moving overseas

% Sick Leave (3) 3.2% 2.8% -0.4% 3.1% 2.8% -0.3%Flu like symptoms among staff despite high vaccination rates

Workplace Injury per 1,000,000 hours (4) 0.0 10.5 10.5 10.6 10.5 -0.1


Falls - % of falls assessments done in first 6 hours (5) 99% 100% -1% 97% 100% -3% Service Managers to follow up with CNMsFalls - % of Interventions completed 86% 100% -14% 95% 100% -5% Service Managers to follow up with CNMsPressure Injuries - % of assessments done in first 6 hours 100% 100% 0% 97% 100% -3%Pressure Injuries - % of interventions completed 88% 100% -12% 98% 100% -2% Service Managers to follow up with CNMs% Over ride rate of Pyxis on AT&R wards (excludes Ward 31) 17% 15% -2% 15% 15% 0% High overrides due to high patient load over Winter


% Acute Stroke Patients Transferred to Inpatient Rehab within 7 days 70% 80% -10% 58% 80% -22%

Despite community service provision, unprecedented high volume and demand for inpatient stroke rehabilitation and high complexity has affected length of stay and patient flow

% Patients Referred to Community Stroke Rehab seen within 7 days 55% 80% -25% 47% 80% -33% Performance improving to meet future MoH target


% Acute Stroke Patients Admitted to Organised Stroke Unit 76% 80% -4% 79% 80% -1%

Unprecented acute load has caused available beds within the Stroke Unit to be immediately filled by acute medical outliers, creating bed blocks for stroke patients

% Eligible Patients Thromboylsed 12% 8% 4% 11% 8% 3%Acute 7 Day Readmission Rate (excludes Stroke and ACE) - Current Month 4.8% 2.9% -1.9% 3.7% 2.9% -0.8% SMOs review readmissions monthlyAcute 28 Day Readmission Rate (excludes Stroke and ACE) 8% 11% 3% 10% 11% 1%

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ADULT REHABILITATION AND HEALTH OF OLDER PEOPLE SCORECARD August 2017En

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MMH % patients discharged to discharge lounge or home by 1100hrs 28% 32% -4% 28% 32% -4%CNMs are regularly reminded to utilise the discharge lounge


% Acute Stroke Patients Admitted to Organised Stroke Unit - Maori/Pacific 59% 80% -21% 78% 80% -2%

Unprecented acute load has caused available beds within the Stroke Unit to be immediately filled by acute medical outliers, creating bed blocks for stroke patients

% Acute Stroke Patients Transferred to Rehab within 7 days - Maori/Pacific 50% 80% -30% 51% 80% -29%

Despite community service provision, unprecedented high volume and demand for inpatient stroke rehabilitation and high complexity has affected length of stay and patient flow


Patient experience rated good or above - month (n=15) and YTD (n=51) 100% 90% 10% 92% 90% 2%P&W

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Mental Health and Addictions Glossary

AOD Alcohol and Other Drugs CADS Community Alcohol and Drug Services FTE Full Time Equivalent GP General Practice/General Practitioner ILoC Integrated Locality Care LOS Length of Stay MH Mental Health MoH Ministry of Health NGO Non Government Organisation PRIMHD Programme for the Integration of Mental Health Data Service Overview

The Mental Health and Addictions division is managed by Tess Ahern (General Manager) with Dr Peter Watson (Clinical Director) and Anne Brebner (Clinical Nurse Director). Highlights

Positive feedback from Waitemata DHB

The following feedback was received from a staff member of Waitemata DHB following support provided by CM Health staff from our acute services to return a patient who was acutely unwell and had been absent without leave from Waitamata DHB Mental Health Services and was found by police. “Morgan, I personally would also ask if there is any way you are able to extend my 'absolute gratitude' to the Counties team members I was directly involved with (I only know them as: Jeremy, Tui and Joy). I wondered if perhaps you were able to send a message to their Manager to acknowledge not only, their incredible support but also, the 'manner' and 'professionalism' they demonstrated, when extending that support to our service. They kept me directly updated every step of the way throughout the whole process of assisting with the patient’s safe return to our unit. In my role that evening as shift coordinator, I want to acknowledge how much their consistent communications helped to make my role significantly less challenging, on what had been an extremely busy and acute shift.” Our staff in mental health work incredibly hard, and often under very challenging and difficult situations, and it is really heartening to receive this positive feedback. Whole of System Integration

• Procurement plan for community-based NGO services was approved by the Board which is a key milestone for progressing our Integration Agenda.

• The Franklin ILoC team has been in place since November 2016, with NGO and CADS FTE joining the team in March/April. The team have been slowly expanding their reach across general practice, schools, aged residential care, and marae. Recent feedback from the Franklin GP Principals Group credited the work of the team for turning mental health services from “one of the most inaccessible services, to one of the most accessible”. A recognition that services needed to be more accessible and flexible was a major driver for the development of the ILoC part of the model of care.

055


• Successful orientation was held in mid-August for the three new ILoC teams. Team composition includes mental health clinicians, Senior Medical Officers, CADS clinicians, and NGO support workers. Teams were excited about working in a new way in a primary care-facing model, and were enthusiastic about their role in growing and developing the model. Teams will be working through how they each operationalise the model within their respective localities, with a view to being ‘active’ during October. With a small initial resource, the teams will be working with locality leadership teams and primary care to identify where the resource should initially be focussed.

New Acute Mental Health Unit

Good progress continues to be made in the clinical areas with roof and wall cladding progressing in many areas now ready for closing in. The administrative zone to the north is receiving the contractor’s full attention as the area is backfilled. Overall progress remains behind that desired and is receiving the greatest attention. Progress inspections are being held weekly with the Contractor’s senior management to monitor progress against the programme. A recent independent programmers report indicates completion as previously reported, however, there is still a lot of work to complete and the unusually inclement weather being currently experienced is not helping weather dependent activities such as roofing and the drying out of timber to allow linings to proceed. The programme is for a mid-January handover of the clinical areas followed by the administrative zone in February. The operational date for Stage two (the Project completion date) is 8 April 2019 and remains unchanged. Preparing the Nursing workforce for the model of care that will be implemented in phase one of the new inpatient unit is also ongoing. Creating regular opportunities for the nursing staff to walk through the new build, review the mock up bedrooms, and consider how nursing care will be provided in a vastly different physical environment is a focus for the nursing team in Tiaho Mai. The Project continues to score high under audit by an external construction health and safety expert and compliance levels remains very high. The Contractor continues to demonstrate high regard for health and safety. Any incidents are discussed prior to each site meeting at a dedicated meeting attended by Occupational Health and Safety. There have been no significant incidents resulting in serious injury over the entire construction period. It was exciting to take the Board on a tour of the site after they received an update with regards to the health and safety practices that are undertaken to ensure staff and contractors are safe during the construction of this new building. Mauri Ora – The Metrics of Flourishing

This seminar given by Sir Mason Durie on 15 August 2017 was attended by staff from Tiaho Mai, the Consumer Engagement service, and the acute community services. The Acute Services Model of Care is based on the work of Sir Mason Durie and draws heavily from the Te Whare Tapa Wha Maori Health model. The conference was an opportunity to hear about the extension of this model and, in particular, the renewed focus on ensuring that alongside of assessments that focus on risks, problems, shortcomings, deficiencies and disadvantage there should also be an assessment of inherent potential. This was a unique and very well received opportunity for staff to consider the work of Sir Mason Durie in relation to updating and revising our own model of care. A focus group made up of attendees has been started with the view to sharing experience of the seminar and considering how the key points can be applied within the acute service.

056


Emerging Issues

Nursing Recruitment

A key issue challenging the division is one of recruitment. We currently have approximately 30 Registered Nurse vacancies, however, have just employed five New Graduate Nurses and four Enrolled Nurses. We are working with the Talent Acquisition team to look at all how to improve in all areas, shortening the ‘time to recruit’, streamlining the interview processes, being more efficient when seeking references, and sharing talent where needed. This remains a work in process and Human Resources are supporting us with this process. We are also looking to increase the new graduate intake for 2017/18 from 18 to at least 25 and will be recruiting these as permanent employees rather than one year fixed term which has been the practice in the past.

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Overtime costs ($000) $205 $149 -37.4% $401 $298 -34.6% High acute demand off-set by community vacanciesBudgeted FTEs 644 705 8.6% 648 705 8.0%Operating Costs ($000) $5,949 $5,978 0.5% $11,831 $11,957 1.1%Personnel Costs ($000) $5,301 $5,633 5.9% $10,563 $11,265 6.2%Financial Result Total ($000) $5,879 $5,916 0.6% $11,705 $11,835 1.1%


% Staff with Annual Leave > 2 years9.3% 5.0%

-4.3%9.1% 5.0%

-4.1%Managers are working with staff on individual plans to reduce annual leave 2 years

% Staff Turnover 11.7% 10.0% -1.7% 10.4% 10.0% -0.4%% Sick Leave

3.9% 2.8% -1.1% 3.5% 2.8% -0.7%Sick leave reviews undertaken with staff with high sick leave

Workplace Injury Per 1,000,000 hours 0.0 10.5 10.5 11.4 10.5 -0.9


Number of Seclusion events/100,000 4.0 5.0 1.0 N/A N/A N/A

Seclusion hours/100,000 76 50 -26 N/A N/A N/AAll seclusion events are reviewed at the weekly risk review meeting

Number of Clients Secluded/100,000 2.8 3.0 0.2 N/A N/A N/A


Shorter wait times for non urgent mental health and addiction Services (%< 3 week wait) - 12 months rolling

0-19 years 70% 80% -10.3% N/A N/A N/A Unique Clients seen has exceeded MOH Target by 134720-64 years 83% 80% 3.1% N/A N/A N/A65+ years 86% 80% 5.6% N/A N/A N/A

Shorter wait times for non urgent mental health and addiction Services (%< 8 week wait)- 12 months rolling

0-19 years 92% 95% -3.5% N/A N/A N/A Unique Clients seen has exceeded MOH Target by 134720-64 years 94% 95% -0.8% N/A N/A N/A65+ years 95% 95% 0.4% N/A N/A N/A


Access rate - Number of CM domiciled unique clients seen by all MH services ((PRIMHD reporting services include AOD and NGO services) 12 months as a % of population) - Total

0-19 years 4.0% 3.2% 0.8% N/A N/A N/A20-64 years 3.9% 3.2% 0.8% N/A N/A N/A65+ years 2.4% 2.6% -0.2% N/A N/A N/A Meeting the wait time targets - no build-up of a waitlist

Readmissions to Tiaho Mai within 28 days - Total (1 month in arrears) 4.5% 12.0% 7.5% 5.6% 12.0% 6.4%

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Inpatient Occupancy - Tiaho Mai Acute Mental Health Unit 97% 85% -11.6% 96% 85% -10.8% Signifies overcrowdingNumber of Tiaho Mai Inpatient LOS >35 days 11 10 -1.0 10 10 0.0


Access rate - Number of CM domiciled unique clients seen by MH services (PRIMHD) 12 months as a % of population - Maori

0-19 years 6.1% 4.5% 1.6% N/A N/A N/A20-64 years 9.0% 7.7% 1.3% N/A N/A N/A65+ years 2.8% 2.6% 0.2% N/A N/A N/A

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Facilities Glossary

BECA An external consultancy service FTE Full Time Equivalent ICR Investor Confidence Rating IT Information Technology MoH Ministry of Health RFP Request for Proposal Service Overview

The Facilities and Asset Management division is led by Philip Healy (General Manager). The division is responsible for Engineering and Facilities, Property Management, Capital Planning, Development and Construction, Clinical Engineering, Transportation and Fleet Management, Infrastructure Services, Enterprise Asset Management, Procurement and Contract Management, Energy Management, Environmental Sustainability, Infrastructure/Facilities, IS Systems, Hazardous Substance, and Safety Compliance/Management. Highlights

ICR National Asset Management and Improvement Plan

CM Health Facilities and Asset Management division (“Facilities”) is the national lead for clinical equipment on the national asset management programme, and has also been heavily engaged with Waitemata DHB on facilities asset management. Facilities, Treasury, MoH, a national DHB asset group, and Opus have engaged in three days of seminars to advance the national asset management programme. The programme has been commissioned by MoH and Treasury to develop a national asset performance measurement framework, based on the following parameters:

• Asset types (specifically facilities, ICT, and clinical equipment), and DHB size and portfolios (small, medium, large).

• Assist with the development of asset performance measures with Cabinet Office Circular (CO (15)5) and Treasury guidance (Annual Report Guidance for Crown Entities: Asset Performance Indicators).

• Assist with improving asset management maturity in line with the Treasury’s ICR for investment-intensive DHBs.

Facilities led the clinical equipment work-stream, with outputs including the development of asset levels of service to demonstrate how the DHB will ensure it delivers the right services at the right levels to meet patient/staff needs and achieve its strategic and regulatory requirements. CM Health Asset Information System

As part of the current Medical IT systems risk review (malware event), Facilities are working with healthAlliance and CM Health’s ICT functions. A proposal from Facilities for an overarching IT governance framework was put forward for consideration. The initiative called GEIT (Governance of Enterprise IT for Healthcare) under COBIT 5 (an internationally recognised framework) is currently under review to see if adopting this can improve CM Health’s response to defining and managing all IT systems regardless of use. Upon endorsement by the working group of the approach, a policy paper will be progressed to the Hospital Management and Executive Leadership Teams for consideration.

060


Regional Innovation Group

healthAlliance has introduced the Regional Innovation Group to encourage sharing of ideas and initiatives among DHBs. CM Health has been active in introducing Facilities-led initiatives which can be syndicated regionally, such as maternity alerting and asset tracking. The group meets fortnightly, moving locations between DHBs. Fleet Management

The healthAlliance RFP for the Northern Region lease vehicles has concluded with a panel of suppliers identified. The documents are waiting for legal review. A work plan for progressing the fleet review has been developed in two sections; one for process and policy, and one for vehicle replacement. An independent supplier has been identified for an upgrade to the booking system and fleet management system. The pool booking system currently in use is old, not responsive to change, and the fleet management company operating the system was bought by a leasing company. This makes working with other lease companies supplying vehicles very challenging. The pool booking system is being trialled throughout September for evaluation. Energy Management

The Energy Management policy was presented to the Hospital Management Team on 21 July 2017. The policy was accepted with a few minor changes. The final policy has now been progressed through the Executive Leadership Team and is awaiting endorsement. The next Utilities Steering Group meeting is scheduled for 12 September 2017 with key items of discussion to be lighting standardisation/roll-out, Manukau SuperClinic continuous commissioning, and next targets for the continuous commissioning programme. The energy pro software is now embedded and training for our Engineers is ongoing. Metering Services Review(s):

Compared to: Electricity Gas All energy Same period last year ↓1.1% ↑5.2% ↑1.9% Weather adjusted target ↑0.5% ↑6.9% ↑3.4%

Interrogation of the apparent increase in gas consumption at Middlemore Hospital has identified (through review of the sub metering and main metering) that the main meter installed towards the end of last year by Genesis is faulty; accordingly Genesis is progressing with a rebate of $70K. A further review of electricity invoices across a number of CM Health sites identified a further rebate of $14K which has now been credited to CM Health. Update on previously reported issues


Regional Water Supply – Potential for Contamination

19 Apr 2017 No change since previous report – this will be considered as part of the proposed Asset Condition Survey (see below).

Devolved Property Management and Leasing

31 May 2017 0.4FTE of a Facilities Team member has been allocated to review and progress this piece of work.

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Asset Condition Survey 31 May 2017 A formal proposal to engage BECA to complete a full Asset Condition Survey is being prepared for the consideration of the Executive Leadership Team. This piece of work has also now been factored into wider facilities planning work underway.

Staff recruitment and retention – Engineering and Clinical Engineering

31 May 2017 Clinical Engineering has and is currently recruiting resources, and is working with Human Resources to develop a retention strategy. As with general engineering, market rates are considerably higher than CM Health’s rates which is making staff retention and attraction challenging.

Galbraith Seismic review

23 Aug 2017 Proposals for the completion of a detailed seismic assessment of the Galbraith building are currently being assessed; a preferred provider will be recommended to the Executive Oversight Panel for endorsement. Both potential providers have indicated this work can be completed within 12 to 16 weeks from the point of engagement.

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Middlemore Central Glossary

AWM Assessment Workload Measurement AT&R Assessment, Treatment and Rehabilitation CCDM Care Capacity Demand Management SSHW Safe Staffing Healthy Workplace TADU Theatre Admission and Discharge Unit Service Overview

Middlemore Central is managed by Dot McKeen (General Manager) with Dr David Hughes (Clinical Director). Highlights

Volumes

While volumes through the Emergency Department remained in the mid-300s during August, the pace of patient flow became more manageable with only five hospital full days recorded (the last being sent 10 August). Report back on actions assigned during previous Hospital Advisory Committee meetings The Committee asked for the “headlines from the 2017 Winter Review Plan”. Winter Lessons Learned Report Work continues to collect the information required to prepare this report, so that we can ensure we provide quality of care 24/7, 365 days a year. This year, presentation of the Lessons Learned will be held in Kidz First meeting rooms 1 & 2 at 9.00am on Tuesday 14 November. A summary of lessons learned is detailed below. Winter started early with higher volumes for May and continued for the next four months.

• Additional areas were utilised for the overnight placement of patients in order to keep some of the flow out of the Emergency Department e.g. Gastro clinic and TADU. The patients for placement were selected from the inpatient wards as being likely to be discharged the following day as they were then sent to the Discharge Lounge at 0700 hours so that the Gastro clinic and TADU could be used for their usual daily workloads.

• Paediatrics also peaked early at the same time which is unusual, and meant that we couldn’t use the Kidz First “C” pod for additional capacity, which we have done in the past.

• The impression initially was that it was a “bad Flu year” when in fact, according to the Infectious Diseases team, it was actually an average year for influenza.

• Patients on medical wards had a longer length of stay compared to previous years which impacted on our ability to flow patients within the organisation contributing to higher hospital occupancy.

• Staffing was also an issue with front line staff becoming unwell, so we deployed record numbers of external bureau staff and casual staff who were less familiar with the wards and the patients.

• The high sick leave level put a greater burden on existing staff. • Over winter there was a total of 43 “Dot Days “ with June being the highest with 12 in the

month.

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Conclusion: Middlemore experienced peak demand not previously experienced and therefore we need to ensure we have progressed facility and workforce planning so that we are prepared for next winter. Summer Plan

With winter now behind us, the division has begun working with Service Managers to plan for summer. This requires us to present a forecast to them specifically for the Christmas/New Year period early enough so that they can align proposed bed closures with annual leave allocation (in particular targeting staff with high annual leave balances). Security

A major piece of work is underway with Human Resources to address the excessive overtime and sick leave totals within the Security service. A new roster has been created which will allow annual leave to be proactively planned and allocated without the use of overtime, which has been the custom; this roster has been presented to the Union and is expected to commence by the end of September. Formal sick leave reviews are also scheduled. Bed Cleaning

Work continues to identify and implement a standard approach for bed cleaning or bed-space decontamination. Several models have been considered in conjunction with key stakeholders, and progress is reported through the Clinical Governance Group meetings. Long stay patients

The Operational Group leading this workstream is currently concentrating on the transition of care from the hospital to the community, especially for those patients whose journey takes them from a medical ward through AT&R and on to residential care. This journey involves ambulance availability, and if clinical equipment is required (e.g. specialist dressing pumps), there are an increased number of hurdles to address. Safe Staffing Healthy Workplace visit

A visit from the CCDM Governance Group took place at the beginning of the month giving us the opportunity to present the data using the AWM accepted by the SSHW unit in Wellington. The Governance group included Chief Executives from Auckland DHB, Wanganui DHB, NZNO, Principal Nurse from the Ministry, and several Directors of Nursing. Following the presentation of our data, which was collected from a variety of wards (Medical, Surgical, and Health of Older People) and validated by Ko Awatea, the Governance group visited several wards to see the AWM being used in practice by nursing staff and to give them the opportunity to talk to nursing staff face to face about the tool, it’s ease of use, and the benefits. SSHW has committed to working with CM Health to further progress our CCDM journey.

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Winter demand and patient flow

23 Aug 2017 High volumes continue to challenge the placement of admissions in a timely manner. The organisation aims for 30% of all discharges into the Discharge Lounge or home by 1100 hours. The management of beds, staffing, and patient flow remained a priority for the division throughout August. Recruitment continues for bureau staff to supplement the workforce and cover sick leave. A total of 20 Registered Nurses and 19 Health Care Assistants have been employed for the Bureau in August. Work continues to develop a dashboard to track the patient journey through the hospital. Currently the production of the dashboard is manual, with some vital measuring points not currently available. We are progressing our acute patient flow measurement dashboard.

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Director of Patient Care, Chief Nurse & Allied Health Professions Officer Prepared and submitted by Jenny Parr, Director of Patient Care, Chief Nurse & Allied Health Professions Officer, with updates provided by the Directorate of Patient Care including Nursing, Midwifery and Allied Health in the hospital, and Primary and Integrated Care. Responses to Action Items Actions previously assigned by the Hospital Advisory Committee are reported back on in this section. HAC Meeting 12.7.2017 – Patient Survey/Complaints Review “Provide a regular update on the response rates to the patient survey and the complaints review process.” Patient Survey An update on the response rates to the patient survey is in the latest National Inpatient Experience Survey which has been reported (May 2017) had a response rate of 22%, and achieved an average of 8.8 out of 10. Each of the four domains was over 8. Complaint Review The complaint review is complete and a preferred option identified for further consultation. See the Quality Assurance section for further information. HAC Meeting 23 August – Diversity Ball “The Committee asked that next year a Board table be reserved at the Diversity Ball”. A Board table is reserved every year for the Diversity Ball and invitations are sent to Board members from the CEO’s office. Highlights Three Nation Approach to Reducing Harm from Falls The Director of Patient Care, Chief Nurse & Allied Health Professions Officer opened this multidisciplinary event which was held on Friday 15 September at the Fisher & Paykel Centre, Auckland Hospital. The event was very well attended and speakers included Dr Frances Healey, Deputy Director of Patient Safety, NHS England, Julie Windsor, Patient Safety Clinical Lead, Medical Specialities and Older People, NHS England as well as Lorraine Lovitt, Lead New South Wales Falls Prevention, Clinical Excellence Commission. New Zealand speakers included sessions from falls programmes at Auckland and Waitemata District Health Boards and Whanganui District Health Board. Frontline Focus Friday An initiative called Frontline Focus Friday is commencing on 22nd September 2017. This weekly forum of frontline managers, led by the Director of Patient Care, Chief Nurse and Allied Professions Officer, or members of her senior leadership team, is designed to support adoption and spread of quality improvement initiatives and support Health and Disability Services Standards certification. It is based on principles of frontline ownership and social movement theory and will be evaluated after 6 months. Allied Health Expo Another successful Allied Health Career expo (a Health Equity Campaign project) was held on Friday 9 September 2017, with around 150 Year 10 Maaori and Pacifica students from local schools

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attending the event. Sixteen different Allied Health professions offered interactive displays of their roles within the Allied Health workforce. Nurse Prescribing The first assessment panel for community nurse prescribing has been undertaken with four portfolios meeting all criteria for credentialing. Another four portfolios require further discussion with the nurses to clarify and confirm clinical decisions made in their case studies. Celebrations A celebration and thank you afternoon tea, hosted by the Director of Nursing, was an opportunity to acknowledge the efforts of the winter influenza peer vaccinators and campaign team. The September 2016 New Entry to Practice programme graduates ‘completion’ ceremony occurred at the end of August. Most of these staff have opted to continue into permanent employment in CM Health. Selection and recruitment for the September New Entry to Practice (NETP) intake is complete. Forty-four graduates commenced on 4 September across hospital and primary care (five graduates across four Primary Care practices). Six Maaori new graduates have all successfully completed their NETP programme. The Director of Patient Care, Chief Nurse & Allied Health Professions Officer presented the certificate for Outstanding Clinical Excellence for the mandatory Post Graduate paper with University of Auckland to Para Pene Nathan. All graduates have been supported into permanent employment. Updated National Adverse Events Reporting Policy In June 2017, the Health Quality Safety Commission published an updated National Adverse Events Reporting Policy1 . The implications of the policy are being worked through, however changes of note are: • A simplified approach to the classification of adverse events so that severity is determined only

by outcome of the event, rather than a combination of likelihood and severity. • Changes to falls SAC scoring e.g. a fall resulting in laceration requiring sutures is now a SAC 3

event. • A new Always Report and Review list2 been provided with an expectation that these are always

reported irrespective of patient harm. • Support for a nationally consistent approach to reporting, review and learning across the whole

health and disability sector, including a single policy and reporting process for events that occur in different parts of the sector.

• A strong focus on consumer involvement in reporting, reviewing and learning from adverse events, including an expectation that the involved consumer and their whaanau will be offered the opportunity to share their story as part of the review process and that review findings and recommendations will be shared with the involved consumer.

• Flexibility to use a wide range of review methodologies, and opportunity to receive feedback from the Commission on reviews. Previously the expectation was that all providers would use a root cause analysis methodology (or, for mental health events, a Serious Incident Review London Protocol).

Workforce Nursing For August, there were 156 FTE Nursing/Midwifery open vacancies. Of the open recruitment, an initial 74 FTE were approved in July – the residual remaining open from prior months.

1www.hqsc.govt.nz/assets/Reportable-Events/Publications/National_Adverse_Events_Policy_2017/National_Adverse_Events_Policy_2017_WEB_FINAL.pdf 2 www.hqsc.govt.nz/our-programmes/adverse-events/publications-and-resources/publication/2936)

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http://www.hqsc.govt.nz/assets/Reportable-Events/Publications/National_Adverse_Events_Policy_2017/National_Adverse_Events_Policy_2017_WEB_FINAL.pdf



http://www.hqsc.govt.nz/our-programmes/adverse-events/publications-and-resources/publication/2936


Of the total vacancies, across CM Health there are 18.3 FTE of Senior Nursing roles, 2.8 FTE of Enrolled Nurse (EN) roles, along with 95.7 FTE of Register Nurse (RN) vacancies (33 FTE of that in community/ambulatory services). Health Care Assistant (HCA) recruitment remains high at 20.8 FTE being recruited (including 8 FTE in community roles). There are 6.0 FTE Midwifery vacancies (inpatient and community), and the ongoing midwifery recruitment and new graduate campaign recruitments. (a) Nursing Workforce Hotspots

Mental Health and Addictions are focused on a commitment towards intentional ‘growth of our own’ mental health nursing workforce. Current vacancy rates are part of a wider national challenge for mental health nursing. Five new graduates have commenced the New Entry to Specialist Practice (NESP) programme, and four ENs have been recruited together, to assist with orientation and support. The service has agreement in principle to increase numbers of new graduate nurses in the two 2018 intakes, and support the clinical areas doing so with a Clinical Coach. In addition, work continues to enhance support systems for existing staff.

Emergency Care, Neonatal Unit, and Specialist Stroke Services are all continuing with focused recruitment campaigns targeting both experienced and new nurses to work at CM Health. Work continues to streamline the ‘time to recruit’ process including efficient interview, reference checking and sharing of suitable candidates across services.

(b) Nursing Pipeline and Education

Planning for the January 2018 NETP intake selection process is now well advanced, with services identifying requirements and ACE portal open for applicants.

The application process for Health Workforce New Zealand (HWNZ) funding (formerly CTA funding) to support Post Graduate Education (Level 8) is currently open. All RNs who work within the CM Health area, including Primary Health Care, Hospice and Aged Care facilities, are eligible to apply. Applications for Health Workforce New Zealand funding close on the 24th September. Clinical Nurse Director Maaori Health has notified all Maaori nurses on staff. Information has been distributed to Primary Health Organisations Nurse Leads for sharing with their nursing staff.

A Postgraduate education open day for Nurses and Allied Health staff occurred on 30 August, at Ko Awatea. Academic representatives from several universities were available to discuss options.

Midwifery Following on from the National Midwifery Advisory Group (NMAG) meeting reported on last month, a presentation by Health Workforce New Zealand (HWNZ) on midwifery workforce projections for the Auckland region by DHB took place on Friday 18 August. This provided the region with the most up to date projections for midwifery workforce required and provided a good framework for further planning. DHB Shared Services are now also linked in to this work. The projected numbers of midwives required is substantial and will require a new strategy for training and retaining midwifery workforce as well as looking at other workforces, models of care and extending multidisciplinary teams (eg: HCAs and the role of RNs in maternity services). The data presented by HWNZ at this meeting highlighted the specific Auckland issues but was not complete as yet, as it had missed DHB employed community midwifery FTE and also the percentages of Midwifery Lead Maternity Carers (LMC) compared with Medical LMC reflecting the different workforces involved. Feedback was provided and the Midwifery Strategic Advisory Group is finalising their work plan in September which will be signed off by HWNZ Board and then distributed to DHBs.

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The regional General Manager’s, Clinical Directors (CDs), and Directors of Midwifery continue to meet monthly to provide updates on the current regional midwifery shortages. Each DHB has different pressures, with ADHB currently having the biggest employed midwifery shortfall and CM Health having shortages in the senior midwifery positions as well as LMC shortages. On 5 September the regional Directors of Midwifery presented an update to the Auckland NZ College of Midwives meeting on each DHB and strategies moving forward. Our new graduate cohort from May is settling in well. Two new graduate midwives started in August as well. The preceptorship model changed this intake to enable the graduates to follow the shifts of one preceptor during their supernumerary rather than working mornings with different preceptors. An evaluation of this change is in process. The pressure area for the service currently is the Birthing and Assessment Unit where the highest midwifery vacancy is of 6.75 full time equivalent (FTE) against budgeted FTE. In addition, there is a skill-mix imbalance, with a cohort of experience midwives having retired or going on parental leave. Birthing and Assessment are to commence their workflow and process project with the assistance of Ko Awatea and following the principles of the Maternity Ward project (Living our Values). The provider Midwifery Strategic Staffing group was reinstated in July with representation from both MERAS and NZNO to discuss local short term strategies and act on feedback and ideas from the midwifery workforce. These meetings occur monthly. Community Midwifery Services have introduced a series of two-hour monthly professional development training sessions for midwifery staff which is recognised by the New Zealand Midwifery Council for recertification hours. These training sessions take place within work time for employed midwives (LMCs are invited) and covers issues of particular relevance to midwives working in a community setting. The first session was held on 26 July and covered renal function for mothers and babies and how to undertake high standards in sending referrals for accessing consultations and input for mothers and babies care. A safe sleep training programme has been initiated for all community midwives based at Lambie Drive. This training is a practice session follow-up to the on-line SUDI training required by the DHB. It has been written and is delivered by our Community Support Workers. The training is aimed to re-visit the safe sleep messages and refresh the consistency and importance of this message. This training further includes information on how to arrange to obtain a pepipod in every community midwife’s car so that midwives can immediately provide one if they discover an unsafe sleeping situation on a home visit, rather than have to return to the office base and send a referral elsewhere to be actioned. Community Nursing Community Health teams remain under pressure with high volumes of referrals received through Community Central up to 155 per day and high sick leave. Some referrals have been redirected to a contracted nursing service to ensure patient care is provided. Staff turnover is high with 31% over the past 24 months. The Maaori Nursing work programme is in progress with Acting Clinical Nurse Director Maaori Health, Nurse Educator Maaori Health, Postgraduate Nurse Coordinator, Nurse Entry to Practice Coordinator, National Hauora Nurse Leader, Nursing Director Procare, Maori Faculty leader and nursing lecturer Manukau Institute Technology, Director of Nursing and Chief Nurse Advisor Primary and Integrated care.

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Te Oohanga Mataora Paetahi Placement Programme – two students from Te Whare Wananga o Awanuirangi are undertaking transition placements at Middlemore Hospital. Both have received good feedback from their preceptors, charge nurse and patients. Both student nurses have applied to Counties Manukau Nurse Entry to Practice programme for employment. The programme will be reviewed in October to identify any improvements required and to scale up in future years. Further work has been undertaken with the NETP and Recruitment Centre team to ‘map’ the ‘end to end’ journey for Māori new graduate nurse applicants. Data from the September 2017 intake suggests that 20/215 applicants who identified as Māori selected CM Health as one of their placement options (Table 1). The majority of Maaori applicants were from the Manukau Institute of Technology (50%) with the remainder applying from schools in the Northern/ Waikato region. NETP Applicants Shortlisted Declined Interviewed Unsuccessful Offered Hired

Maaori 20 20 8 11 5 6 5

Pacific 22 22 3 19 4 13 9

Table 1: Maaori and Pacific NETP applicants - September 2017 Out of the 20 Maaori applicants, 5 were hired in the September 2017 intake. Three nurses were employed in Inpatient Services, two were employed in Primary Care and one was employed into Mental Health Services. All graduates are now offered permanent employment contracts. This number is similar to previous years (refer CM Hospital Advisory Committee papers Appendix 1, August 2017). Investigations into the poor conversion to interview and employment rate reveal only anecdotal data. The reasons why Maaori applicants are a) not taken to interview and b) are unsuccessful at interview has been identified. It has been recommended that a better process to collate data is implemented. In preparation for the January 2018 new graduate intake, a number of process improvements have been proposed. These include: • All applicants who identified as Maaori will be reviewed by the Acting Clinical Nurse Director and

Nurse Educator – Māori Health. This will provide a better opportunity to understand the interest and level of support required for our future workforce and support the shortlisting and interview process.

• Revision of the interview and assessment centre process. This includes integration of drug calculation tests (or similar) into the assessment centre scenarios and revision of the panel interview questions to ensure alignment with values-based recruitment.

• A recommendation that all Maaori and Pacific applicants are interviewed first and that there is Māori nursing representation on all Māori applicant panels and a Pacific nursing representative on all Pacific applicant panels.

Following completion of the September 2016 intake, the first cohort of the Maaori Nurse entry to practice initiative it is timely to consider what has worked and what could be improved. Feedback from ProCare and NHC PHO Nurse Leads has been positive with good team work cited between Counties Manukau Health Nurse Entry to Practice Programme and Recruitment team. The variation in programmes across the metro region was also discussed, with Primary Heath Organisation Nurse Leaders expressing a preference for the Counties Manukau Health approach. Two Māori new graduates are eligible for Maaori health funding in the September 2017 intake. Allied Health (a) Speech and Language Therapy

The speech and language therapists have achieved and maintained 100% full membership to the New Zealand Speech Language Therapy Association (NZSTA) across the CM Health workforce.

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Speech Language Therapists are participating in a Careers Networking event for graduating Speech and Language Therapy students from the University of Auckland (UoA) and Massey University (MU), to be held on the evening of 27 September. CM Health, Speech and Language therapists and CM Health Talent Acquisition are joining forces to showcase CM Health as a first-choice employer for Speech Language therapists in the early years of their career.

(b) Occupational Therapists

Current hotspot vacancies remain in Mental Health, however some improvement has been seen since last month’s report, including the successful appointment of a senior Maaori Occupational Therapist for the Manukau community team. This required significant negotiation as this therapist is unable to work full time and generally this has been a requirement in Mental Health. There are still 4 vacant FTE’s and recruitment is looking at various options for attracting applicants.

(c) Anaesthetic Technicians

Great success has been achieved in the recruitment and training of anesthetic technicians over the last (nearly) four years. The ability to train more people and bring them on twice-yearly has made a big difference. The FTE has increased significantly and the team has been extremely supportive.

Patient Experience Enabling Voting The District Health Board has supported the Electoral Commission to provide patients the opportunity to vote between 18-22 September. Three teams of two people were accompanied by a Justice of the Peace to oversee the process to ensure it is carried out correctly. The Justice of the Peace was also able to assist any voter who requests help completing their voting papers. On election day itself, 23 September, static voting services were provided to mobile patients who have not yet voted, staff and visitors during the legislated hours of 9am – 7pm. Consumer Feedback and Learning Ko Awatea has been supporting the development of a pipeline of Patient Stories for presentation to the Board, other committees and for training. It has been a great benefit to patients to be supported by staff experienced in consumer engagement, media and journalism. The first story will be shown at the Board meeting in October. Efforts to boost participation and email collection for both the National Survey and Inpatient survey continue, with email collection by area being monitored. Improving the Environment Preparations are underway for the opening of the new Mental Health unit in February 2018 continues, with nursing staff having regular opportunities to walk through the new build, review ‘mock-up’ rooms, and consider how care will be provided in the much-improved environment. The opportunity to focus fundamentally on patient and staff experience is valuable for all.

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Maximising Independence The new model for supporting patients on medical wards who have acute delirium is showing early positive results. HCAs on two wards are providing enhanced ‘carer’ role, rather than being a purely ‘watch’ to reduce risk. Where possible, these patients are cohorted to support appropriate orientation, interactions, and assistance with daily cares. This has seen a reduction in need for bureau HCA watches on the ward, and released this to other areas in the hospital. Patient Experience Empathy Zone The Associate Director for Occupational Therapy took a leadership role in the event on 13 September. This was a valuable opportunity to help future health professionals understand the impact of their role from the patient’s perspective. All students on placement were invited to participate. Improving the Experience of Food and Nutrition There has been ongoing support provided by the Dietitian Assistant in improving the communication from wards through Task Manager Meal Information (TMMI) system about appropriate menu allocation. The Charge Nurses (CNs) have responded well to this communication and this team work has overwhelmingly improved the accuracy of menu selections on TMMI. As a result of this, there has been a request for ongoing education at the ward level on how to appropriately complete TMMI for selecting menus. There have been conversations with the Director of Nursing and Ko Awatea resulting in the possibility of developing e-learning modules and this option is currently being explored.

Work continues to be done by Compass on planning meals for patients with allergies not currently supported through the current TMMI pathway. Changes are required of the Saffron system to alert ‘other allergens’ chosen. These IT changes are a work in progress. There is a manual process for Compass staff to ensure other allergens are identified and only appropriate foods are offered on the spoken menu as well as alert the kitchen trayline. This issue has improved here recently with only one incident in the last 6 weeks which was human error. This is now resolved. Compass is receiving a 53% feedback rate from their monthly survey distribution. They have identified 9 areas of feedback all which met their KPI’s although taste, size and temperature of meals were less than 95% satisfaction. Methods to improve in these areas are being explored such as Food Service Assistant training, upskilling and auditing. The primary drivers for poor satisfaction with hot food include delivery timeliness of trolley to the ward, timeliness of meal tray hand at ward level and temperature of food at trayline. Observations of the meal trolley process in these wards will be completed in September to understand how temperature of food is impacted. Volunteer Services A Volunteer Coordinator has been successfully recruited to coordinate the Volunteer Service. Lee Bouman comes with solid experience in managing volunteers but is new to the hospital sector. He is completing an orientation programme and is also undertaking a stocktake of current activities and business needs and updating the list of current volunteers at both the Manukau Super Clinic (MSC) and Middlemore Hospital (MMH) sites. The Manukau Super Clinic Shuttle Service The Northern Shuttle Service route for patients was resumed on 10 July. As the service is dependent on volunteer drivers it is proving to be a challenge to cover the shifts when volunteers are unavailable. Given this, there is no immediate plan to re-establish the Southern Shuttle Service route. A longer term and more sustainable plan will need to be developed.

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The Manukau Super Clinic Mailroom The sending of clinic letters to patients has been entirely dependent on the volunteer workforce, however with a recent decline in the volunteer numbers at MSC alternative options are being explored to ensure the longer term sustainability of this service. The immediate risk is being managed within existing resources and a business plan for the longer term management is being considered. Quality and Improvement Nursing Initiatives that Improve Efficiency and Flow There have been a variety of actions to address these challenges. This has included the introduction of Nurses providing ‘acute flow coordinator’ roles in ED, Medicine and Surgery; working groups comprising frontline staff looking at effective ways of reducing ‘stranded patient’ events, and making process improvements for key activity such as discharge cleaning and transfer of care processes. Surgical Services are working on the initial concepts for a ’23-hour’ unit linked to the Post-Anaesthetic Care Unit (PACU). To further assist with hospital winter capacity, a pop-up ward for selected patients during winter and provided the PDSA tests of several concepts. Technology Enabled Care Many of the Healthy Technology projects are entering their implementation rollout phase involving intensive work with sponsoring departments, which is seeing many changes in clinical routines. This phase of the rollout of each system and the new point-of-care devices across Middlemore Hospital, Manukau Surgery Centre, and Manukau Super Clinic takes the programme into patient care areas and collaboration with service leaders. While CM Health has learnt from other DHBs, the sequence of projects ready for implementation is different. Service demand and intensity variations influence the level of clinical workflow analysis, training, and support required for rollout. A series of recent workshops and discussions with services have focused on ensuring service continuity and determining how best to resource the rollout with staff training and support. (a) Clinical Documentation Programme - e-Vitals:

The introduction of e-vitals to early adopter wards (one medical and one surgical) has commenced, with early positive results and narrative. Concurrently, CM Health is commencing an organisation-wide change in assessment of deteriorating patients. This will see a move away from use of the Physiologically Unstable Patient (PUP) assessment tool to the New Zealand Early Warning Score (NZEWS). The intention is to ‘switch off’ the current PUP tool, replacing it with NZEWS across CM Health. The NZEWS system applies international best practice, which each hospital then incorporates with their local escalation process for responding to deteriorating patients.

The introduction of NZEWS is integrated into the e-vitals programme for recording patient observations and assessments, including NZEWS on digital devices. The project team are working with all wards and units to introduce the new format, explain how it works and how it benefits our patients. As e-vitals is introduced to more areas, the transition to NZEWS will also occur. Nurse Educators and the e-vital clinical coaches will provide staff training and a new e-learning course is already available on Ko Awatea Learn.

(b) Care Capacity Demand Management (CCDM)

The Steering Group hosted a visit by the national Safe Staffing/Healthy Workplace Unit in late July, as part of system validation. Feedback from the national Governance Group discussion sessions has been helpful to setting future priorities for the work. It will be helpful to work closely with other DHBs to support benchmarking and reliability of the tool.

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Midwifery The CM Health Women’s Health and Newborn Annual Report 2016-2017 was submitted to the Ministry of Health on 1 September after being reviewed by both the Maternity Quality and Safety Group and the Maternity Strategy Group, before it went to Executive Leadership Team for sign off. This year’s annual report expanded to involve the Gynaecology Department and saw the Newborn section include projects specifically focused on improving care for neonates, along with NNU statistics. The Women's Health & Newborn Annual Report 2016-2017 launch is occurring on 20 September 17. The Senior Advisor, Maternity Services at the Ministry of Health, Bronwen Pelvin has accepted an invitation to attend. A Postnatal Guideline and Schedule of Care have been developed for all community midwives employed by CM Health. The aim of this guideline is to outline a clear shared understanding of what postnatal midwifery care women and babies should expect to receive and what care community midwives should expect to deliver. This guideline outlines a timeline for visit dates, the care and information offered to women and babies, where to document in MCIS and what follow-up is expected from each episode of care. The guideline also includes the postnatal non-contact process for community midwifery staff in order to outline what actions are required in the case of non-contact with women and babies in the postnatal period of 42 days. The guideline also provides an easy to use schedule of visits as a quick-glance reference. The Postnatal Triage Process forms part of the expectation in the Postnatal Guideline and is supplied as a separate document. The Triage Process outlines what to do with a new postnatal referral. Following five serious adverse events within the last year within Women’s Health where there was retention and delay in the removal of per vaginum (pv) packs, recommendations have included documentation clarification, education of all staff and development of a hot pink ‘pv pack in situ’ sticker. These stickers and the process for application have been approved by Women’s Health Clinical Leaders Group. The Health Quality Safety Commissioners introduction of the Always Report and Review List on 1 July 17 includes retained swabs. Community Nursing It has been identified that due to staff turnover the community health teams have a skill mix gap. Chief Nurse Advisor Primary and Integrated Care and Nurse Consultant Primary and Integrated Care plan to look at each community health team’s skill mix and identify key staff for development. The service needs to have succession plans in place for the senior nurses who are nearing retirement. Development of key performance indicators for community health teams is underway in collaboration with general and operations managers. Acute beds stay, system level measure contribution – Cellulitis. Opportunity to scope earlier supported discharge for people to be supported by community health team for completion of intravenous antibiotics and home visits to assess person, provide health education on keeping well and follow up to support completion of treatment. Allied Health (a) Occupational Therapy

Health Alliance has approved the procurement trial application after the Wound Care Service outlined another spate of heel pressure injuries. The clinical evaluation form is in the process of being approved and a set of 20 Maxxcare heel Pro booties donated by Morton and Perry. The Section Head Occupational Therapist (Acute Allied Health) will coordinate the trial with the Wound Care Service.

(b) Physiotherapy

CM Health Physiotherapy service successfully passed a surveillance audit and they have done CM Health proud.

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Surveillance Audit Executive Summary - this audit against the Allied Health Services Sector Standard NZS 8171:2005 included a review of the quality and risk management plans, policies and procedures, patient and staff files and other relevant documentation, observation and interviews with management and staff.

CM Health physiotherapy department has several strengths. • In particular is their ongoing initiative and professional drive that occurs from the

physiotherapists within each department for continued professional development and furthering of the profession.

• The momentum of this drive is not a top-down structure, but is initiated from the physiotherapists working within each department, deciding on what they would like to achieve, and being well supported, financially and professionally, to work towards those goals.

CM Health has also achieved a unique balance in their ability to manage such a large and varied workload, while still maintaining client-centred care, and developing ongoing innovations.

This is reflected in their achievement of fully attained ratings against all criteria. CM Health physiotherapy department is encouraged to continue to strive to achieve ‘Continued Improvement’ ratings, the gold standard of quality improvement processes, in future quality audits. The auditor would like to thank the physiotherapy staff involved in this surveillance audit for their time and efforts. And congratulate them on achieving full attainment of all criteria. There are no corrective actions.

(c) Nutrition and Dietetics

The Associate Director Allied Health (ADAH) Dietetics was involved in a six week collaborative partnership project between Massey University dietetic students, CM Health Manukau Locality project manager and General Manager, and CM Health Kindergarten Association. Dietetic students utilised the Kindergarten Association play trucks for the use of promoting good nutrition in a community setting. This also involved cooking demonstrations; vegetable.co.nz was very involved and provided a large portion of the sponsorship for the project. This was a highly successful project, and the communications team has been alerted to help profile this. This was the first time this type of integration of services has been trialed and was a great example of true collaboration for the benefit of patient knowledge.

A new initiative looking at wrap around support has begun within the Otara-Mangere locality. The aim of this is to develop a clinically co-designed clinician designed led and implemented service for those who are defined as ‘morbidly obese’. ADAH Dietetics will have ongoing discussions and links with this project.

Meetings have been held recently with ‘Green Prescription’ to find a collaborative approach to obesity management across the CM Health district. This means a service review of existing clinical pathways for those referred for weight loss, including women who require nutritional input to avoid developing diabetes in pregnancy. A pathway for referral to green prescription has been identified and is currently being further explored.

A CAPEX application was made for a Bioelectrical Impedance Spectroscope (BIS) - a tool to analyse body composition and consequently determine nutrition requirements. One has been temporarily borrowed from Clinical Trials as the perfect opportunity arose to demonstrate effectiveness of our interventions. It was used on an extremely long term patient (admitted Nov 2016) to show lean tissue mass improvements from Total Parenteral Nutrition and exercise, which is hoped to improve surgical outcomes. Surgeons are now interested in the process and keen to understand the outcomes and implication to practice.

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(d) Hand Therapy From the beginning of August 2017, the Hand Therapy team dispensed with writing prescriptions for orthotic splints and have moved to electronic billing via iPMs, an electronic data system (as done with all other consumables). This is a significant improvement and therapists are delighted in the reduction in administration involved in issuing orthotics.

Quality Assurance (a) Certification Update

The recent establishment of the Corrective Action Group Monitoring (Chaired by the Director of Patient Care, Chief Nurse and Allied Health Professions Officer) has improved traction on five corrective actions that were identified by the Ministry as making ‘slow progress’. This has resulted in improved traction and, in particular, the Plan of Care (PoC) project is a highlight as initial trials in Medicine and Surgery indicate that it will make significant improvement to the areas that were identified as deficient in the April 2016 Certification audit (evaluation, assessment and planning). In light of this, KidzFirst and Women’s Health are reviewing the format and projects initial findings for leverage and alignment with work on care plans/models of care underway in these areas.

The next Certification visit has been confirmed for February 2018. It will focus on corrective actions. Planning is underway for the visit which will involve the completion of a self- assessment template and submission of evidence prior to the visit. The Corrective Action Monitoring Group will revise its scope to monitor of all Corrective Actions now that the ‘slow to progress’ Corrective Actions have improved their traction.

(b) Complaint Review Update

Two of the corrective actions from the last Certification audit were to (a) improve our complaint process and (b) develop a Corrective Action Database for Complaints and Serious and Sentinel Events (SSE). The complaint review is complete and a preferred option identified for further consultation. The preferred option was one of three posed and of the three, it offers the least change while still delivering considerable benefit at no extra cost. It proposes the establishment of a new Head of Feedback and Adverse Events role (reporting to the Director of Patient Care, Chief Nurse and Allied Health Professions Officer). The Head will provide professional leadership and coordination to both feedback (complaints in particular) and Serious and Sentinel Events (SSE). They will lead a small centrally located team called ‘Feedback Central’. The proposals are being prepared for consultation with affected staff.

The need to improve the Risk Management System software was highlighted in the above complaint review, so monitoring and reporting can be strengthened. We are refreshing our requirements (based on work undertaken in 2015). There are two software vendors in the market (used by other District Health Boards). In the meantime, alternative options for a Corrective Action Database are being actively explored. Two workshops have been held with the Clinical Quality and Risk Managers to identify format and resource needed.

(c) Corrective Action Database

An excel database for SSE has been populated with corrective actions from the last year and is being trialled. The Chief Medical Officer manages an excel spreadsheet to monitor and coordinate the Health and Disability Commissioner (HDC) complaint recommendations. However it is limited in its reporting ability so it is likely that the SSE database could be adapted to cater for the complaint corrective action monitoring.

(d) Controlled Documents

At the time of our April Certification audit the number of overdue controlled documents (policies, procedures, and guidelines) was 18% and we incurred a corrective action as a result. For a variety of reasons this has recently increased to 28%. This is despite changing the review period from 2 years to 3.

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There are many reasons for the difficulty in achieving a 0% of overdue documents however workload of those involved in updating the documents (many of who are clinical staff) is probably the most obvious. However there are other (systemic) factors that also contribute, such as the devolved Local Document Controller structure (support roles for the process), a lack of clarity around the responsibilities of those who ‘own’ the documents and support the process, reporting issues (data integrity in particular), and a growing number of controlled documents (currently over 2000).

The Controlled Document Committee has recently developed a Procedure that gives greater clarity around roles and responsibilities and process. It also introduces a new responsibility for the Committee of approving ‘new’ controlled documents at the initiation phase. An improved report format has also been developed which should be more user friendly and provide greater visibility to a wider group of stakeholders including General Managers. The Controlled Document Committee has a work plan which includes additional strategies such as training (on the Documentation Directory) KPI setting.

Leadership Nursing Recruitment for a new Clinical Nurse Director for ARHOP continues and is expected to be announced imminently. The role will provide a strong leadership for continued integration of Older People and Rehabilitation services across community and hospital settings. Community Nursing The Chief Nurse Advisor Primary and Integrated Care attended the National Nursing Organisation Meeting in her role as Chair of Nurse Executive New Zealand. Discussion on the future of the new nurse of the future being the flexible responsive health worker as a generalist role in the health system paper. Chief Nurse Advisor Primary and Integrated Care provided advice to New Zealand Nurses Organisation Collective Bargaining discussion on nurse prescribing for the current wage negotiations. Allied Health (a) Speech and Language Therapy

A Senior Speech and Language therapist was appointed as New Zealand Speech and Language Association (NZSTA) area representative. This role involves co-ordination of area meetings, response to local issues and communication with local members.

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This will greatly increase CM Health interface with national organisations, as well as increasing collaboration and working relationships with our professional colleagues at Ministry of Education and other the other local DHBs.

Another CM Health Senior Speech and Language Therapist has been nominated for a position on the NZSTA Executive Council, as Maaori and Cultural Development postholder, and have contributed to He Kete Whaunangatanga, a consultative project for the NZSTA.

(b) Nutrition and Dietetics

Work completed by a Senior Diabetes Dietitian was highlighted in the recent Women's Health and Newborn Annual Report. This was highlighting the end of the Dietary and Lifestyle Advice Workshops that were provided to Lead Maternity Carers and other Healthcare workers who manage pregnant women with an abnormal glucose blood count. These workshops were introduced to support the implementation of the ‘Ministry of Health (MoH) Guideline for Screening and Diagnosis of Gestational Diabetes Mellitus (GDM).’ The pilot workshops were well received and had excellent outcomes.

(c) Occupational Therapy

Progress has been made to enable Occupational Therapists in Mental Health and Addictions to be able to prescribe Band 1 equipment, (basic equipment eg: shower stool, commodes etc). Members of the Equipment Team and Section Head Occupational Therapist presented at the South Auckland Mental health meeting on 5 September 2017, to explain and demystify the process of getting equipment credentialing to the Mental Health Occupational Therapists. The plan is to up-skill Mental Health for older people clinicians and inpatient (Tamaki Oranga and Tiaho Mai) first, and then continuing into community Mental Health. There is no expense to complete this course, however time and support is needed for Occupational Therapists to complete the theory and practical parts of the course. The time frame for Occupational Therapists to gain accreditation is four months from the time they start the course.

Patient Safety Plan of Care Small-scale plan-do-study- act (PDSA) testing of the Plan of Care documentation commenced on one surgical and one medical ward on 10 July. Audit results from the Plan of Care testing from the pilot wards (33 East and 10) indicate improvements have been made in standards of documentation from a baseline of 48 per cent to 81 per cent compliance on the 21 documentation criteria using the gold audit tool following implementation of the Plan of Care form and use of the assessment, implementation and evaluation (AIE) format to document in the clinical notes. As such, the target of between 80-90 per cent compliance to meet certification requirements (Plan of Care project aim) has just been met. Further education and sharing of these audit results to the pilot wards will occur over the next few weeks. Champions and auditors have been identified to continue the frontline leadership of this work going forward. The audit findings, project progress and next step plans were discussed at a meeting with the project sponsors on 8 September. Falls Prevention In Adult Rehabilitation & Health of Older People (ARHOP), wards 23, 24 and 31 have joined Ward 4 in the plan-do-study-act (PDSA) tests of the Post Fall Checklist to look at improving post falls review and documentation. The PDSA is to test whether completing the Post Fall Checklist assists with decision making and prompts action immediately after the fall and provides clearer documentation about the fall for the purpose of incident reporting and case review.

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At the ARHOP Charge Nurse Manager meeting a decision was made to cease the test of the multidisciplinary post fall huddle analysis template and process on Ward 24 as the huddle process was proving challenging to complete and was not providing additional or improved information. The Community Falls programme was launched on 1 September. Primary Care nurses will systematically screen all older people over 75 for risk of falls. Referrals will then be made to community group strength and balance programmes, in conjunction with Age Concern Counties Manukau or in-home strength and balance programmes provided by CM Health physiotherapists. All referrals will be sent to Community Central for allocation to a programme. The community physiotherapists have developed an online mobility and falls module that is followed by a practical session. The package upskills clinicians to complete a basic mobility assessment and teaches them how to check exercises programmes. It guides them as to when the patient would need to be seen by a physiotherapist or whether they can manage these themselves. This has been trialed in Mangere/Otara locality with great success. Reablement clinicians will be trained in the other Localities, aiming to have achieved this by mid-October. Patient Safety Week A Patient Safety Week Working Group has been established to plan for national Patient Safety Week (PSW) which will be held on Monday 6 to Friday 10 November 2017 and will be facilitated by the Health Quality & Safety Commission (the Commission) in partnership with ACC and with support from PHARMAC. The theme for this year’s Patient Safety Week is ‘Let’s Talk Medicines’. The Commission’s reasons for choosing this theme is that (1) it aligns with the World Health Organisation’s global patient safety challenge on medication safety; (2) in the national in-patient experience survey, the question “Did a member of staff tell you about medication side effects to watch for when you went home?” consistently gets one of the lowest scores and, (3) there are a large number of medication errors and adverse events related to high-risk medicines in particular can be extremely serious. The theme of ‘Let’s Talk Medicines’ will have a focus on encouraging consumers to understand and ask questions about their medicine; and to encourage health professionals to communicate medicines information to consumers and to ensure consumers have understood. The following three consumer questions will be the focus: What is my medicine called?; What is it for? and, When and how should I take it?

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Human Resources (HR) Quarterly reporting item - Annual Leave Cashups within the Hospital Services Directorate A summary of the annual leave cashups within the Directorate for the period 1 June to 31 August 2017 is provided below.

Regular reporting items HR metrics are provided to outline performance for Annual Leave Balances, Sick Leave and Turnover rates. Below are the 12 month trend graphs to July 2017.

RC Name Category Ttl AL Cash Up

(hrs) Current AL

Balance (hrs) Ttl AL Taken in

12 Months (hrs)

Adult Emergency Care Family 40.00 299.00 40.00

CMC Awhinatia Annual Leave Reduction Project 386.32 381.54 482.32

Continuity of Care Annual Leave Reduction Project 69.00 446.07 69.00

Diabetes Service Annual Leave Reduction Project 133.24 492.92 335.24

Gastroenterology Annual Leave Reduction Project 201.49 468.78 0.00

Microbiology Family 91.68 374.99 139.68

Grand Total

921.73 2,463.30 1,066.24

7%8%9%

10%11%12%13%14%15%

Percentage of CMDHB Workforce with Annual Leave Balances > 2 Years' Equivalent (Hospital Directorate Only)

> 2 Years > 2 Years LY UCL Average LCL

0%

4%

8%

12%

16%

20%

Annual Leave Paid as Percentage of Total Paid Hours August 2016 to July 2017

AL Paid % AL Paid % LY UCL Average LCL

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0%

1%

2%

3%

4%

5%

6%

Sick Leave as Percentage of Total Paid Hours (for the Hospital Directorate Only)

Sick Leave Sick Leave LY UCL Average LCL

6%7%8%9%

10%11%12%13%

Annualised CMDHB Voluntary Turnover (Hospital Directorate Only)

Turnover Turnover LY UCL Average LCL

12.1%

15.6%

6.2%

11.4% 11.4% 12.1%

16.3%

9.1%

0%

5%

10%

15%

20%

25%

Voluntary Turnover by Occupational Group August 2016 - July 2017

Turnover CMDHB Average Previous Year Previous Month

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0 10 20 30 40 50 60 70 80

Aug'16

Sep'16

Oct'16

Nov'16

Dec'16

Jan'17

Feb'17

Mar'17

Apr'17

May'17

Jun'17

Jul'17

Voluntary Employee Turnover by Reason for Leaving August 2016 to July 2017

Personal To go overseas Another job in public healthLeft district Resigned RetiredJob outside of health Job in Private health EducationJob dissatisfaction Unpaid work

48%

31%

12% 6% 3%

Total FTE Hired - July 2017

Nursing

Allied Health

Admin/Management

Medical

Non Clinical Support

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Counties Manukau District Health Board Resolution to Exclude the Public Resolution: That in accordance with the provisions of Schedule 3, Clause 32 and Sections 6, 7 and 9 of the NZ Public Health and Disability Act 2000: The public now be excluded from the meeting for consideration of the following items, for the reasons and grounds set out below:

General Subject of items to be considered

Reason for passing this resolution in relation to each item

Ground(s) under Clause 32 for passing this resolution

2.1 Public Excluded Minutes of 23 August 2017

That the public conduct of the whole or the relevant part of the proceedings of the meeting would be likely to result in the disclosure of information for which good reason for withholding would exist, under section 6, 7 or 9 (except section 9(3)(g)(i))of the Official Information Act 1982). [NZPH&D Act 2000 Schedule 3, S32(a)]

Confirmation of Minutes For the reasons given in the previous meeting.

3.1 Patient Experience and Safety Report

That the public conduct of the whole or the relevant part of the proceedings of the meeting would be likely to result in the disclosure of information for which good reason for withholding would exist, under section 6, 7 or 9 (except section 9 (2) (g) (i)) of the Official Information Act 1982). [NZPH&D Act 2000 Schedule 3, S32 (a)]

Privacy The disclosure of information would not be in the public interest because of the greater need to protect the privacy of natural persons, including that of deceased natural persons. [Official Information Act 1982 S9(2)(a)]

3.2 Facilities Master Plan That the public conduct of the whole or the relevant part of the proceedings of the meeting would be likely to result in the disclosure of information for which good reason for withholding would exist, under section 6, 7 or 9 (except section 9(3)(g)(i))of the Official Information Act 1982. [NZPH&D Act 2000 Schedule 3, S32(a)]

Communication with the Sovereign The disclosure of information would not be in the public interest because of the greater need to enable the Board to maintain the constitutional conventions for the time being which protect the confidentiality of communications by or with the Sovereign or her representative. [Official Information Act 1982 S9(2)(f)]

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