HOSPITAL ADVISORY COMMITTEE (HAC) MEETING · ZW ] v v tZvµ v ^ v v t ] ]}vW }P uu .[ The Committee Chair acknowledged the presentation and noted the complexity of the programme

HOSPITAL ADVISORY COMMITTEE (HAC) MEETING

Wednesday 09 May 2018 1.30pm

A G E N D A

VENUE

Waitemata District Health Board Boardroom Level 1, 15 Shea Tce Takapuna

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Waitemata DHB Hospital Advisory Committee Meeting 09/05/18

HOSPITAL ADVISORY COMMITTEE (HAC) MEETING 09 May 2018

Venue: Waitemata DHB Boardroom, Level 1, 15 Shea Terrace, Takapuna Time: 1.30pm

Committee Members James Le Fevre – Committee Chair Max Abbott – WDHB Board Member Kylie Clegg – WDHB Chair Sandra Coney – Deputy Committee Chair Brian Neeson – WDHB Board Member Morris Pita – WDHB Board Member Allison Roe – WDHB Board Member cc All Waitemata DHB Board Members

WDHB Management Dale Bramley – Chief Executive Officer Robert Paine – Chief Financial Officer and Head of Corporate Services Andrew Brant – Deputy Chief Executive Officer and Chief Medical Officer Jocelyn Peach – Director of Nursing and Midwifery Cath Cronin – Director of Hospital Services Joanne Brown – Funding and Development Manager, Hospitals Tamzin Brott – Director of Allied Health Fiona McCarthy – Director Human Resources Peta Molloy – Board Secretary

APOLOGIES: Brian Neeson

AGENDA

DISCLOSURE OF INTERESTS Does any member have an interest they have not previously disclosed?

Does any member have an interest that might give rise to a conflict of interest with a matter on the agenda?

PART I – Items to be considered in public meeting

All recommendations/resolutions are subject to approval of the Board.

2. CONFIRMATION OF MINUTES

1.30pm 2.1 Confirmation of Minutes of Hospital Advisory Committee Meeting (28/03/18) Actions Arising from previous meetings

3. PROVIDER REPORT

1.35pm

3.1 Provider Arm Performance Report Executive Summary Human Resources

Acute and Emergency Medicine Division Specialty Medicine and Health of Older People Services Child, Women and Family Services Specialist Mental Health and Addiction Services

Surgical and Ambulatory Services/Elective Surgery Centre

4. CORPORATE REPORTS

2.50pm 3.05pm 3.15pm

4.1 Clinical Leaders’ Report 4.2 Human Resources Report 4.3 Quality Report

5. INFORMATION ITEMS

3.30pm 5.1 Winter Plan 2018

3.40pm 6. RESOLUTION TO EXCLUDE THE PUBLIC

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Waitemata District Health Board

Hospital Advisory Committee Member Attendance Schedule 2018

Attended the meeting x Absent * Attended part of the meeting only # Absent on Board business ^ Leave of absence

NAME FEB MAR MAY JUN AUG SEP OCT DEC

Max Abbott x

Kylie Clegg

Sandra Coney x

James Le Fevre (Committee Chair)

Brian Neeson

Morris Pita x

Allison Roe x

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Register of Interests

Hospital Advisory Committee

Board/Committee Member

Involvements with other organisations

Last Updated

Max Abbott Pro Vice-Chancellor (North Shore) and Dean – Faculty of Health and Environmental Sciences, Auckland University of Technology Patron – Raeburn House Advisor – Health Workforce New Zealand Board Member, AUT Millennium Ownership Trust Chair – Social Services Online Trust Board member – Rotary National Science and Technology Forum Trust

19/03/14

Kylie Clegg Trustee - Well Foundation Director – Auckland Transport Director – Sport New Zealand Trustee and Beneficiary - Mickyla Trust Trustee and Beneficiary - M&K Investments Trust (includes a share of less than 1% in Orion Health Group)

29/04/18

Sandra Coney Member – Waitakere Ranges Local Board, Auckland Council Patron – Women’s Health Action Trust Member – Portage Licensing Trust Member – West Auckland Trusts Services

15/12/16

James Le Fevre Board member – Auckland District Health Board Emergency Physician – Auckland Adults Emergency Department Pre-hospital Physician – Auckland HEMS – ARHT/Auckland DHB Trustee – Three Harbours Foundation Member – Medical Protection Society Member – ACEM Hospital Overcrowding Subcommittee Shareholder – Pacific Edge Ltd DHB Representative (Auckland and Waitemata DHBs) – Air Ambulance Codesign Procurement Governance Board. James’ wife is an employee of the Waitemata DHB, Department of Anaesthesia and Perioperative Medicine and a Medico-Legal Advisor for the Medical Protection Society

14/02/18

Brian Neeson Member – Upper Harbour Local Board Member – Human Rights Review Tribunal Member – Auckland District Licensing Committee Managing Director – BK & VS Neeson Limited Managing Director – Apollo Property Investments Limited Property Development Consultant Brian’s son-in-law is employed by the Housing Corporation and is undertaking work for Unitec related to its Mt Albert site development.

18/04/17

Morris Pita Owner/operator – Shea Pita and Associates Limited Shareholder – Turuki Pharmacy Limited Member - Eden Park Trust Board Shareholder and Director of Healthcare Applications Limited Morris’ wife is member of the Northland District Health Board and the Auckland District Health Board

08/12/16

Allison Roe Chairperson – Matakana Coast Trail Trust Member - Rodney Local Board, Auckland Council

02/11/16

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2.1 Minutes of the Hospital Advisory Committee Meeting held on 28 March 2018

Recommendation:

That the draft minutes of the Hospital Advisory Committee meeting held on 28 March 2018 be approved.

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Minutes of the meeting of the Waitemata District Health Board

Hospital Advisory Committee

Wednesday 28 March 2018

held at Waitemata District Health Board Boardroom, Level 1, 15 Shea Terrace, Takapuna, commencing at 1.35pm

PART I – Items considered in public meeting COMMITTEE MEMBERS PRESENT

James Le Fevre (Committee Chair) Max Abbott Kylie Clegg Brian Neeson Allison Roe

ALSO PRESENT

Warren Flaunty (Waitemata DHB, Board Member) Dale Bramley (Chief Executive Officer) Fiona McCarthy (Director of Human Resources) Jocelyn Peach (Director of Nursing and Midwifery) Tamzin Brott (Director of Allied Health) Joanne Brown (Funding and Development Manager-Hospitals) Penny Andrew (Clinical Leader Quality) Peta Molloy (Board Secretary) (Staff members who attended for a particular item are named at the start of the minute for that item.)

PUBLIC AND MEDIA REPRESENTATIVES

There were no members of the public or media representatives present.

WELCOME

The Committee Chair welcomed those present. APOLOGIES

Apologies were received and accepted from Morris Pita, Sandra Coney, Andrew Brant, Cath Cronin and Jacky Bush.

DISCLOSURE OF INTERESTS

James Le Fevre advised that he was now a member of the Northern Region Clinical Practice Committee.

There were no declarations of interest relating to the open section of the agenda.

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1. AGENDA ORDER AND TIMING Due to timing constraints of reporting officers, the public excluded section of the meeting was held before the open section of the meeting. Item 4.3 of the open meeting was considered before item 3.1 and a presentation held after item 2.1; the remaining items were taken in the same order as listed in the agenda. 1.37pm to 1.54pm - the open meeting adjourned for consideration of the public excluded section of the meeting.

2. COMMITTEE MINUTES

2.1 Confirmation of the Minutes of the Hospital Advisory Committee Meeting held on 14 February 2018 (agenda pages 5 to 12) Resolution (Moved Kylie Clegg/Seconded Allison Roe) That the Minutes of the Hospital Advisory Committee meeting held on 14 February 2018 be approved. Carried Actions Arising (agenda page 13 )

Noted.

PRESENTATION

Dr Jocelyn Peach (Director of Nursing and Midwifery) presented to the Committee on ‘Patient and Whanau Centred Care Standards and Ward Accreditation Programme.’ The Committee Chair acknowledged the presentation and noted the complexity of the programme. He queried the underlying success factors for the level of uptake. In response Jocelyn advised that a framework was needed and welcomed, which assisted with the level of uptake, coupled with the leadership in place. In addition, matters covered in discussion and response to questions included:

That the programme is frequently reviewed with a view to reduce the number of audits undertaken. It is proposed that audits be undertaken six-monthly for regular monitoring on Wards and to highlight improvements.

Noting that there is potential to partner with the University of Auckland to review and validate the programme.

That the there is a time commitment to undertake the programme, however, it does not impact patient care.

3. PROVIDER ARM PERFORMANCE REPORT 3.1 Provider Arm Performance Report – January 2018 (agenda pages 14 to 74)

The Committee Chair queried the DHB’s influenza planning, in response the Chief Executive advised that the DHB is reviewing its pandemic readiness and escalation

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plans in preparation if there is an influenza outbreak. Fiona McCarthy noted that there are over 100 nurses ready to provide vaccinations within the organisation over a four week period, in both static clinics and on Wards. In addition the Chief Executive noted that TransforMED is assisting with occupancy at the DHB; metro Auckland Chief Operating Officers are working together to develop a winter plan including the provision of assistance from neighbouring DHBs if required. TransforMED is now being implemented at Waitakere Hospital. The volumes through the emergency department in January 2018 were higher than normal, which appears to have been experienced nationwide. Volumes dropped following that, but an increase has been seen in recent weeks. Human Resources (agenda page 32 to 35)

Fiona McCarthy (Director, Human Resources) summarised this section of the report, noting in particular sick leave management and that some reduction in annual leave is expected. In response to a question from the Board Chair about challenges to recruit within the cleaning service, Fiona noted that innovative campaigns are underway and the DHB has recruited in this area. She also noted that there are changes within the DHB with staff undergoing career opportunities and moving to new roles in the organisation.

Acute and Emergency Medicine Division (agenda page 36 to 43)

Alex Boersma, (General Manager, Acute and Emergency Medicine) summarised this section of the report. Matters covered in discussion and response to questions included:

The Board Chair noted the Government’s focus on road safety and improvement, she queried whether the DHB kept data in this area; in response Alex advised that some data is kept, however, Waitemata DHB would not receive high trauma cases as these are bypassed to Auckland DHB and Counties Manukau DHB Emergency Departments.

The Committee Chair noted the reported ‘seen by time for orthopaedic patients at 45% seen within two hours of triage’ and queried whether the service structure needed to be reviewed; in response Alex advised that work is underway with ADU and there is an opportunity to improve patient flow.

Specialty Medicine and Health of Older Persons (agenda page 44 to 49)

Dr John Scott (Head of Division) and Brian Millen (General Manager, Medicine and Health of Older People Services) presented this section of the report. With regard to the Kingsley Mortimer Unit update, it was noted that a further report will be submitted to the Committee on the review of the short, medium and longer term solutions to increase capacity in community to care closer to home and community settings. It was further advised that due to the Government’s Mental Health Inquiry, the deep dive for long term planning in this area will be deferred until the inquiry is completed. With regard to possible impact on patients in delaying the deep dive, Brian noted that the service has acute visibility of people entering the service and that there have not been any adverse events on the waiting list. The

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Kingsley Mortimer Unit is a working high acuity ward that achieved gold in their care standards. In response to a query from the Committee Chair regarding service delivery for diagnostic colonoscopies within 42 days being below target (59% against a target of 70%), Brian advised that the service had received unusually high demand over the December 2017/January 2018 period. It is anticipated that this rate will be improved by April 2018 with near target achievement in May 2018. Child Women and Family (agenda page 50 to 56)

Emma Farmer (Head of Division Midwifery) and Stephanie Doe (General Manager Child, Women and Family Services) were present for this item. An apology from Dr Meia Schmidt-Uili (Division Head) was noted. Stephanie Doe introduced the report noting the highlight of the month ‘Implementation of the Healthy Housing Initiative’; a further update on this initiative and its metrics will be provided to the Committee at its next meeting. Matters covered in discussion and response to questions included:

That with regard to the Auckland Regional Dental Health Services update, an audit of sterilisation processes has been undertaken in ten clinics to identify improvements. Work will be undertaken on an improvement plan including the use of disposable instruments (in liaison with the DHB’s sustainability officer).

Noting the collaborative model between nursing and midwifery reported. Emma Farmer further advised that a cohort of nurses had been recruited to work in maternity and with midwives and will be looking after women and babies; this is intended to be a long term model of care.

That work with vulnerable children happens in variable ways across the DHB’s services, including ‘friends and family’ on the paediatric ward as well as an App being developed where children can draw their experiences. It was noted that privacy/or obtaining a parents permission had not been an issue for the DHB; communication is key with/and for the family and this is managed.

That the delivery of fluoride varnish for pre-schoolers (page 56 of the agenda) is for the prevention of dental disease; it was noted that only 35 per cent of pacific children have no dental caries.

The Committee Chair thanked the team for the update, noting in particular the detailed improvement plan and the positive recruitment in midwifery. Specialist Mental Health and Addiction (agenda page 59 to 65)

Susanna Galea (Head of Department, Mental Health Services) and Alex Craig (Head of Division Nursing, Mental Health) summarised this section of the report. Matters covered in discussion and response to questions included:

Noting that it is possible to achieve a zero seclusion rate; procedures are in place to do this and include learning to identify when a client is becoming agitated and how to manage that for each individual (as one person may need space and another may need people to support them).

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Noting the DHB’s low rate of seclusion for Maori clients, where other DHBs show higher rates. Alex Craig said that this is a reflection of close engagement with Kaumatua and recognising an individual client’s needs.

That the Substance Addiction Compulsory Assessment and Treatment Act (SACAT) came into effect on 21st February 2018. Data to date for enquires and assessments were reported (page 61 of the agenda), with six applications for treatment made and three people now under the Act. It was noted that if data is extrapolated then there is likely to be in the region of 500 enquiries a year with a significant number then under the Act. Susanna noted that there is a concern of the impact on voluntary clients; each enquiry takes between 10 to 20 hours of work.

With regard to numbers of clients being admitting under SACAT to the treatment centre in Christchurch, it was noted that there has been one person admitted from the Christchurch area, another in process under certificate from the Wellington area and the remainder are from the Waitemata district.

That the scorecard details waiting times for clients to be seen in Community, Drug and Alcohol services.

The Committee Chair acknowledged the work around managing the implementation and implementing SACAT. Susanna Galea advised that the DHB has engaged with the mental health enquiry panel, who will be visiting the DHB on 10 May. There is particular interest in understanding how the DHB has a rapidly growing population in its district and continue with high standards of care.

Surgical and Ambulatory Services/Elective Surgical Centre (agenda page 66 to 74)

Debbie Eastwood (General Manager) presented this section of the report. Apologies were received from Dr Michael Rodgers (Chief of Surgery) and Kate Gilmour (Head of Division Nursing). Debbie summarised the report. Matters covered in discussion and response to questions included:

The Committee Chair noted the combination of low theatre utilisation and outsourcing for ORL; in response Debbie advised that this was due to workforce issues.

Querying whether the updated provided on higher than ‘budgeted volumes and more complex case mix driving clinical supplies costs’ were related to incorrect budget assumptions; Debbie advised that clinical supplies in a clinical environment can be challenging when identifying what is required.

The report was received.

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4. CORPORATE REPORTS

4.1 Clinical Leaders’ Report (agenda pages 75 to 80)

Tamzin Brott (Director of Allied Health) presented this item. Apologies were received from Andrew Brant (Deputy Chief Executive and Chief Medical Officer) and Jocelyn Peach (Director of Nursing and Midwifery; Emergency Systems Planner). Medical Staff

This section of the report was noted. Nursing and Midwifery

This section of the report was noted. Allied Health, Scientific and Technical Staff

Tamzin Brott summarised this section of the report. The update provided on the new graduate programme was mentioned and it was noted that there are six dental therapists in the pilot. The report was noted.

4.2 Human Resources (agenda pages 81 to 90)

Fiona McCarthy (Director of Human Resources) summarised the report. Allison Roe queried the ‘return to nursing programme,’ information will be provided to Allison on this programme. The report was noted.

4.3 Quality Report (agenda pages 91 to 182)

This item was received before item 3.1. Penny Andrew (Clinical Lead Quality) presented this item. It was noted that the mortality rate is sustaining a downward trend. Penny advised that a mortality workshop has been established that has three key areas: family escalation, national early warning score and goals. Work is underway on establishing a new early warning system. An update will be provided to the Committee on this work. The report was noted.

5. RESOLUTION TO EXCLUDE THE PUBLIC (agenda page 183) This item was considered before item 2. Resolution (Moved Allison Roe/Seconded Brian Neeson)

That, in accordance with the provisions of Schedule 3, Sections 32 and 33, of the NZ Public Health and Disability Act 2000:

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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

1. Confirmation of Public Excluded Minutes – Hospital Advisory Committee Meeting of 14/02/18

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, S.32 (a)]

Confirmation of Minutes As per resolution(s) to exclude the public from the open section of the minutes of the above meeting, in terms of the NZPH&D Act.

2. Quality Report That the public conduct of the whole or the relevant part of the proceedings of the meeting would be likely to result in the disclosure of information for which good reason for withholding would exist, under section 6, 7 or 9 (except section 9 (2) (g) (i)) of the Official Information Act 1982. [NZPH&D Act 2000 Schedule 3, S.32 (a)]

Privacy The disclosure of information would not be in the public interest because of the greater need to protect the privacy of natural persons, including that of deceased natural persons. [Official Information Act 1982 S.9 (2) (a)]

3. Human Resources Report

That the public conduct of the whole or the relevant part of the proceedings of the meeting would be likely to result in the disclosure of information for which good reason for withholding would exist, under section 6, 7 or 9 (except section 9 (2) (g) (i)) of the Official Information Act 1982. [NZPH&D Act 2000 Schedule 3, S.32 (a)]

Privacy The disclosure of information would not be in the public interest because of the greater need to protect the privacy of natural persons, including that of deceased natural persons. [Official Information Act 1982 S.9 (2) (a)] Negotiations The disclosure of information would not be in the public interest because of the greater need to enable the board to carry on, without prejudice or disadvantage, negotiations. [Official Information Act 1982 S.9 (2) (j)]

Carried The meeting concluded at 4.12 pm. SIGNED AS A CORRECT RECORD OF THE WAITEMATA DISTRICT HEALTH BOARD HOSPITAL ADVISORY COMMITTEE MEETING OF 28 MARCH 2018 COMMITTEE CHAIR

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Actions Arising and Carried Forward from Meetings of the Hospital Advisory Committee

as at 03 May 2018

Meeting Agenda Ref

Topic Person Responsible

Expected Report Back

Comment

18/10/17 3.1 Provider Arm Performance Report A presentation from Helen Wood about the mental health workplace policy to be rolled out across all United Nation agencies.

Noted. Helen Wood is overseas and will be contacted on her return.

28/03/18 4.2 Human Resources Request from Allison Roe for information on the ‘return to nursing programme’.

Fiona McCarthy

Actioned. Information provided.

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3.1 Provider Arm Performance Report – February 2018 Recommendation:

That the report be received.

Prepared by: Robert Paine (Chief Financial Officer and Head of Corporate Services) and Cath Cronin (Director of Hospital Services)

This report summarises the Provider Arm performance for February 2018.

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Table of Contents

Glossary

How to interpret the scorecards

Provider Arm Performance Report – February 2018

Executive Summary / Overview

Scorecard – All services

Health Targets

Elective Performance Indicators

Strategic Initiatives

Financial Performance

Human Resources

Divisional Reports

Acute and Emergency Medicine Division

Specialty Medicine and Health of Older People Division

Child, Women and Family Services

Specialist Mental Health and Addiction Services

Surgical and Ambulatory Services

Elective Surgery Centre

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Glossary

ACC - Accident Compensation Commission ADU - Assessment and Diagnostic Unit ARDS - Auckland Regional Dental Service AT&R - Assessment Treatment and Rehab CADS - Community Alcohol, Drug and Addictions Service CT - Computerised Tomography CWF - Child, Women and Family service DHB - District Health Board DNA - Did not attend ED - Emergency Department ECHO - Echocardiogram ESC - Elective Surgery Centre ESPI - Elective Services Performance Indicators FTE - Full Time Equivalent LOS - Length of Stay MRI - Magnetic Resonance Imaging MoH - Ministry of Health NSH - North Shore Hospital ORL - Otorhinolaryngology (ear, nose, and throat) PFB - Patient Focussed Booking RMO - Registered Medical Officer S&A - Surgical and Ambulatory Services SMHA - Specialist Mental Health and Addiction Services SMO - Senior Medical Officer WIES - Weighted Inlier Equivalent Separations WTH - Waitakere Hospital YTD - Year To Date

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How to interpret the scorecards Traffic lights For each measure, the traffic light indicates whether the actual performance is on target or not for the reporting period (or previous reporting period if data are not available as indicated by the grey bold italic font).

Actual Target Trend

Better help for smokers to quit - hospitalised 98% 95% The colour of the traffic lights aligns with the Annual Plan:

Traffic light Criteria: Relative variance actual vs. target Interpretation

On target or better Achieved 95-99.9% achieved 0.1–5% away from target Substantially Achieved

90-94.9%*achieved 5.1–10% away from target AND improvement from last month Not achieved, but progress made

10% away from target

Not Achieved

Trend indicators A trend line and a trend indicator are reported against each measure. Trend lines represent the actual data available for the latest 12-months period. All trend lines use auto-adjusted scales: the vertical scale is adjusted to the data minimum-maximum range being represented. The small data range may result in small variations appearing to be large. Note that YTD measures (e.g., WIES volumes, revenue) are cumulative by definition. As a result their trend line will always show an upward trend that resets at the beginning of the new financial year. The line direction is not necessarily reflective of positive performance. To assess the performance trend, use the trend indicator as described below. The trend indicator criteria and interpretation rules:

Trend indicator

Rules Interpretation

Current > Previous month (or reporting period) performance Improvement

Current < Previous month (or reporting period) performance Decline

Current = Previous month (or reporting period) performance Stable

By default, the performance criteria is the actual:target ratio. However, in some exceptions (e.g., when target is 0 and when performance can be negative (e.g., net result) the performance reflects the actual. Look up for scorecard-specific guidelines are available at the bottom of each scorecard:

1. Most Actuals and targets are reported for the reported month/quarter (see scorecard header).

2. Actuals and targets in grey bold italics are for the most recent reporting period available where data is missing or delayed.

3. Trend lines represent the data available for the latest 12-months period. All trend lines use auto-adjusted scales: the vertical scale is adjusted to the data minimum-maximum range being represented. Small data range may

result small variations perceived to be large.

a. ESPI traffic lights follow the MoH criteria for funding penalties:

ESPI 2: the traffic light will be green if no patient is waiting, blue if greater than 0 patients and less than or equal to 10 patients or less than 0.39%, and red if 0.4% or higher.

ESPI 5: the traffic light will be green if no patient is waiting, blue if greater than 0 patients and less than or equal to 10 patients or less than 0.99% and red if 1% or higher.

Key notes

Trend indicator

Traffic light Measure description

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Provider Arm Performance Report

Executive Summary/Overview

Summary The Provider has completed the January-March quarter and maintained high levels of perofrmance across a number of metrics. As you will read in the report the divison clinical leads are focusing on clinical indicators identified by clinicans to showcase their achieviements and also to identify areas for continual improvement in clinical outcomes and patient experience.

Highlight of the month Fonterra visit A senior team from Waitemata DHB met with a senior team from Fonterra. We enjoyed meeting with a non-health sector, successful co-operative and we were very interested in how many of our areas of focus were similar rather than dissimilar (… and we both have COWs). We discussed and shared ideas in innovation, collaboration and competitors, stakeholder relations including government, quality and provision of service, staff wellbeing, quality and risk. We have decided to keep in contact to explore shared opportunities further and Fonterra will visit the DHB this year.

Key Issue of the Month Winter and Flu Planning We have convened our team to ensure we are prepared for the potential winter flu. Reports from overseas reported high influenza rates and we are increasing our activity early. Our teams are focusing to improve practice with infection prevention and control measures, availability of in-house flu testing with rapid turn- around time. We have our in-hospital response plan completed including cohorting in dedicated winter wards in case of increased flu activity if required. A focus for the next couple of months will be our immunisation programme.

We strongly recommend that all our staff are immunised. Dr Jocelyn Peach (Director of Nursing and Midwifery) is pictured with Dr Sudesh Dixit (Emergency Medicine Doctor) at WTH recently.

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Financial Performance Summary The Provider Arm result for the month ended February 2018 was favourable by $65k. The Provider Arm continues to implement the Financial Sustainability Portfolio which is a multi-year portfolio of initiatives to drive sustainable reductions in expenditure and generate revenue. Strategic initiatives such as TransforMED are continuing to deliver benefits through reduced average length of stay as the transition to business as usual.

Scorecard – All services

Actual Target Trend Elective Volumes Actual Target TrendShorter Waits in ED 96% 95% Provider Arm - Overall 99% 100% Faster cancer treatment (62 days) 95% 90%

Waiting Times

ESPI 2 - % patients waiting > 4 months for FSA Compliant

ESPI 5 - % patients not treated w/n 4 months Compliant

ESPI 1 - OP Referrals processed w/n 10 days CompliantPatient Experience Actual Target Trend

Complaint Average Response Time 9 days


Health Targets Faster Cancer Treatment

Shorter Stays in Emergency Departments

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Inpatient Events admitted through ED

Emergency Department/ ADU Presentations

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Improved Access to Elective Surgery

Note: Changes were made to the electives health target for 2015/16

Percentage Change ED and Elective Volumes

February 2018 Month Volumes % Change (last year) YTD Volumes % Change (last year)

ED/ADU Volumes 10,164 4% 86,965 6%

Elective Volumes 1150 5% 9370 4.2%

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Elective Performance Indicators Zero patients waiting over four months

Summary (February 2018)

Speciality Non Compliance %

ESPI2 0.19%

ESPI5 0.50%

ESPI WL Specialty Compliant Non Compliant

ESPI 2 Anaesthesiology 153 1 0.65%

Cardiology 788 - 0.00%

Dermatology 219 - 0.00%

Diabetes 150 - 0.00%

Endocrinology 239 - 0.00%

Gastro-Enterology 718 3 0.42%

General Medicine 151 - 0.00%

General Surgery 1,275 1 0.08%

Gynaecology 938 1 0.11%

Haematology 244 - 0.00%

Infectious Diseases 51 - 0.00%

Neurovascular 98 - 0.00%

Orthopaedic 1,773 8 0.45%

Otorhinolaryngology 1,636 6 0.37%

Paediatric MED 650 - 0.00%

Renal Medicine 188 - 0.00%

Respiratory Medicine 564 - 0.00%

Rheumatology 150 - 0.00%

Urology 551 - 0.00%

Total 10,536 20 0.19%

ESPI 5 Cardiology 137 - 0.00%

General Surgery 1,215 3 0.25%

Gynaecology 390 - 0.00%

Orthopaedic 749 7 0.93%

Otorhinolaryngology 423 6 1.40%

Urology 267 - 0.00%

Total 3,181 16 0.50%

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90% of outpatient referrals acknowledged and processed within 10 days

ESPI 1 (February 2018)

Specialty Compliance %

Anaesthesiology 100.00%

Cardiology 96.69%

Dermatology 95.45%

Diabetes 100.00%

Endocrinology 97.01%

Gastro-Enterology 98.28%

General Medicine 97.37%

General Surgery 94.39%

Gynaecology 100.00%

Haematology 97.99%

Infectious Diseases 98.70%

Neurovascular 95.74%

Orthopaedic 98.58%

Otorhinolaryngology 95.83%

Paediatric MED 100.00%

Renal Medicine 100.00%

Respiratory Medicine 99.08%

Rheumatology 96.03%

Urology 99.68%

Total 97.67%

Discharges by Specialty

Legend

ESPI 1 Green if 100%, Yellow if between 90% and 99.9%, and Red if 90% or less.

ESPI 2 Green if 0 patients, Yellow if greater than 0 patients and less than or equal to 10 patients or less than 0.39%, and Red if 0.4% or higher.

ESPI 5 Green if 0 patients, Yellow if greater than 0 patients and less than or equal to 10 patients or less than 0.99%, and Red if 1% or higher

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Cumulative Bed Days saved through Hospital Initiatives

Predicted versus Actual Bed Days

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Strategic Initiatives Variance Report Deliverable/Action On Track

Faster Cancer Treatment

1. We will implement sustainable service improvement activities to improve access, timeliness and quality of cancer services.

2. Confirm a process to ensure all tumour streams appropriately apply the High Suspicion of Cancer flags – December 2017.

Work with Māori Health to (EOA):

3. Appoint a Māori Cancer Nurse Coordinator – September 2017.

4. Develop and implement a work plan to ensure equitable health outcomes for Māori patients – September 2017.

5. Document a clear pathway for all external and internal HSC P1 (high priority) gastroenterology patients, in conjunction with the Gastroenterology Service – September 2017.

6. Design a process to ensure all cancer follow-up patients are identified and receive follow-up at the correct time – December 2017.

7. Contribute to the development of plans for local delivery of medical oncology – developed by December 2017.

8. All cancer-related MDMs will use electronic forms to document meeting outcomes – in place by June 2018.

9. Improve waiting times for diagnostic CT and MRI by reviewing options to increase capacity and implement changes to service model of care and delivery to improve planned patient access – December 2017.

National Bowel Screening

10. Meet the bowel screening quality standards for the Waitemata DHB programme – ongoing.

11. Continue to meet the waiting time standard for bowel screening colonoscopies – ongoing.

12. Waitemata DHB bowel screening programme structure and staffing in place to join the national programme – January 2018.

Areas off track for month and remedial plans

All areas on track.

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Financial Performance

($000’s)

Actual Budget Variance Actual Budget Variance Budget

REVENUE

* Government and Crown Agency 71,846 72,588 (742) 585,286 581,646 3,640 872,524

Other Income 2,314 2,816 (502) 20,563 19,961 602 32,357

Total Revenue 74,160 75,404 (1,244) 605,849 601,607 4,242 904,881

EXPENDITURE

Personnel

Medical 12,997 14,871 1,874 118,004 119,208 1,205 181,197

Nursing 19,787 20,130 343 159,029 159,319 289 239,669

Allied Health 9,027 9,240 214 74,251 77,445 3,193 116,926

Support 1,567 1,561 (6) 12,652 13,101 450 19,785

Management / Administration 5,405 5,384 (21) 45,321 44,304 (1,017) 67,214

Outsourced Personnel 372 1,028 656 9,540 8,444 (1,097) 12,735

49,156 52,214 3,058 418,797 421,821 3,024 637,525

Other Expenditure

Outsourced Services 4,032 3,842 (190) 34,703 31,328 (3,375) 46,854

Clinical Supplies 9,919 9,007 (912) 82,000 76,266 (5,734) 115,847

Infrastructure & Non-Clinical Supplies 9,726 9,079 (647) 81,829 74,317 (7,513) 111,654

23,677 21,928 (1,749) 198,533 181,911 (16,621) 274,356

Total Expenditure 72,833 74,142 1,309 617,330 603,732 (13,598) 911,881

Cost Net of Other Revenue 1,327 1,262 65 (11,481) (2,125) (9,356) (7,000)

Waitemata DHB Statement of Financial Performance

MONTH YEAR TO DATE FULL YEAR

Provider - February 2018

Comment on major financial variances The Provider result was $9.356m unfavourable to budget for the YTD to February 2018. The key variances are described below. Revenue Revenue was $4.242m favourable to budget due primarily to revenue from MoH and Inter-District flows. Expenditure Personnel ($3.024m favourable) The favourable variance was driven by vacancies across all service areas.

Other Expenditure ($16.621m unfavourable) The unfavourable variance was driven by unbudgeted expenses and unrealised expenditure reduction initiatives. Outsourced Services ($3.375m unfavourable) The unfavourable variance was due to unbudgeted outsourced radiology, gastroscopy and colonoscopy services. These procedures continue to be outsourced to meet MoH targets and population demand.

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Clinical Supplies ($5.734m unfavourable) The unfavourable variance was driven by unbudgeted costs for clinical supplies, inpatient pharmaceuticals and unbudgeted repairs and maintenance.

Infrastructure and Non-Clinical Supplies ($7.513m unfavourable) The unfavourable variance was driven by Facilities and Development ($1.545m) YTD due to unbudgeted repairs and maintenance and unrealised expenditure reduction initiatives. S&A ($3.585m) YTD due to unrealised expenditure reduction initiatives. Getting back on track Initiative The Provider Arm is progressing a comprehensive multi-year portfolio of initiatives to drive sustainable reductions in its cost base. The portfolio is executive lead, pan-directorate with regular status reporting. The portfolio includes strategic focus on both clinical transformation and value-based programmes of work along with a DHB wide improvement portfolio of over 200 service lead projects focused on enhanced productivity and quality, workforce deployment, procurement and supply chain and revenue optimisation. One such initiative is TransforMED which has reduced Average Length of Stay leading to a reduction in operating costs.

($000’s)


CONTRIBUTION

Surgical and Ambulatory (13,175) (12,105) (1,070) (106,904) (99,884) (7,020) (153,031)

Acute and Emergency (11,375) (10,583) (791) (92,052) (90,053) (1,998) (138,468)

Specialty Medicine and HOPS (6,622) (5,848) (774) (55,277) (51,952) (3,325) (80,175)

Child Women and Family (6,723) (6,522) (202) (54,653) (55,195) 542 (85,319)

Specialist Mental Health and Addiction (9,614) (9,837) 223 (80,503) (82,336) 1,833 (126,742)

Elective Surgery Centre (2,256) (2,305) 49 (17,841) (18,507) 666 (28,295)

Corporate and Provider Support 51,091 48,462 2,630 395,749 395,804 (55) 605,030

Net Surplus/Deficit 1,327 1,262 65 (11,481) (2,125) (9,356) (7,000)



Provider - February 2018

Comment on major variances by Provider Service The Provider result was $9.356m unfavourable to budget for the YTD February 2018. The key variances are described below: Surgical and Ambulatory ($7.020m unfavourable YTD) The variance was driven by increased unbudgeted RMO expenditure due to unbudgeted over allocations and ongoing unbudgeted outsourcing expenditure associated with Radiology. Radiology procedures continue to be outsourced to meet MoH targets and population demand. Increasing clinical supplies costs, unbudgeted repairs and maintenance, other one-off costs and unrealised expenditure reduction initiatives have also had an unfavourable impact. Acute and Emergency Medicine ($1.998m unfavourable YTD) The variance was driven by unbudgeted increased RMO costs due to over allocations, pricing variations and increased allowance costs. The strategies for reducing costs over the balance of the year will focus on optimising the operational efficiency gains being achieved from the TransforMED ‘Home Warding’ initiative through maximising leave consumption and opportunistic bed closures.

Specialty Medicine and HOPS ($3.325m unfavourable YTD) The variance was driven by outsourced gastroscopy and colonoscopy procedures, and increased demand for high-level respite care for complex needs patients and a change to the model of care in the Kingsley Mortimer Unit.

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Child, Women and Family ($542k favourable YTD) The variance was driven by higher than planned vacancies across Allied Health, Management/Administration and to a lesser extent, Medical staffing groups. Partially offsetting this are unmet cost reduction initiatives. The service continues to work through issues regarding staff retention and roster cost pressures within Maternity services as well as high clinical equipment repairs and maintenance costs and demand-driven clinical supplies.

Specialist Mental Health and Addiction Services ($1.833m favourable YTD) The variance was due to vacancies in nursing, partially offset by casual staff and overtime cover. There were also vacancies in medical which was partly offset by locum cover. To minimise vacancies, a retention and recruitment committee explore ways of attracting and retaining staff.

Elective Surgery Centre ($666k favourable YTD) The variance was driven by lower than planned personnel costs, package of care volumes and clinical supplies as a result of lower than expected volumes and case mix variances. Corporate and Provider Support ($55k unfavourable YTD) The Corporate and Provider Support Services YTD result is marginally unfavourable YTD. This is a result of unrealised budgeted financial sustainability initiatives across Corporate and Provider Support and unbudgeted inpatient pharmaceuticals and patient meal contract price increases in Hospital Operations. These unfavourable variances are offset by an adjustment in the accrual for Continuing Medical Education following an in year review in February 2018.

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Human Resources Method of calculation of graphs:

1. Overtime Rate: the sum of Overtime Hours worked over the period divided by Worked Hours over the period.

2. Sick Leave Rate (days): the sum of Sick Leave Hours over the period divided by Total Hours over the period. 3. Annual Leave balance 0-24 days: count of Staff with less than 25 equivalent 8 hour days accumulated leave

entitlement. 4. Annual Leave balance 25-49 days: count of Staff with between 25 and 50 equivalent 8 hour days

accumulated leave entitlement. 5. Annual Leave balance 50-74 days: count of Staff with between 50 and 75 equivalent 8 hour days

accumulated leave entitlement. 6. Annual Leave balance 75+ days: count of Staff with over 75 equivalent 8 hour days accumulated leave

entitlement. 7. Voluntary Turnover Rate: count of ALL staff resignations in the last 12 months. This data excludes RMOs,

casuals, and involuntary reasons for leaving such as redundancy, dismissal and medical grounds. 8. Internal Turnover: involves employees leaving their current positions and taking new positions within the

same organisation. 9. External Turnover: involves employees leaving their current positions and taking new positions outside of the

organisation.

Sick Leave Sick leave for February is 3.1%, which is within our target, but close to our upper limit for this time of the year. All provider divisions are sitting within the target level reflecting a slightly elevated rate since the last report. However, as we are now moving into the autumn/winter period where sick leave traditionally increases due to colds, flu and other seasonal illnesses, proactive monitoring and management across all areas will continue. Influenza vaccinations commence on 23 April 2018 and the campaign to encourage staff to be vaccinated is well underway. The Healthy Workplace Strategy includes a range of work streams and activities which contribute to maintaining health and wellbeing of our staff and the continued roll out of these strategies is expected to assist in the ongoing reduction of sick leave absences. A verbal update on the influenza vaccination rate will be provided at the meeting.

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Overtime Overtime has also increased during this reporting period some of which will have been driven by increased sick leave cover and some by vacancies and patient acuity. The consistent drivers of the overtime rate sitting above the upper tolerance for the organisation continue to be Hospital Operations and SMHA. Hospital Operations are reporting an overtime rate of 4.9% for this period. The twelve monthly average is at 4.1%. The overtime rate’s key driver is cover for Cleaner vacancies at NSH. While there has been improvement since last reporting period there is still a combined vacancy level of 12.7FTE. The recruitment assessment centres have provided a good number of candidates but we continue to implement a range of strategies to address the remaining vacancies including:

Weekly recruitment campaigns.

Dedicated student resource focused solely on recruiting to Hospital Operations.

Change advertising campaign approach – recruiting to specific roles/shifts.

Monthly meetings with the service and recruitment centre.

Working with Work and Income New Zealand on attracting applicants. SMHA rate for this month is 5.2% with the twelve monthly average sitting at 4.5% with trend reporting reflecting continued steady increase, with the costs sitting predominantly in nursing and driven by vacancies and high acuity patients. Overtime is continually monitored with both Adult and Forensic inpatient units having rolled out new overtime reporting in the last month. This new reporting is being used to assess where other specific initiatives could make a difference. At least 40% of overtime is unrelieved meal breaks and work to remove this allowance from the overtime data is underway. Both Divisions maintain rigorous monitoring and continue to implement strategies targeted at reducing over time rates.

Annual Leave The annual leave balance per person is 22 days (24 in December) and this is the same as last year. This is a good effort given over the last 12 months we have increased our FTE and that anyone transferring to the DHB from another DHB can bring their existing leave balances.

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Annual Leave Management (headcount)

Leave Balance

0-25 days

Leave Balance

25-50 days

Leave Balance

50-75 days

Leave Balance

75 days +

Surgical and Ambulatory 879 318 66 26

Elective Surgery Centre 100 15 1 0

Child Women and Family Services 918 151 21 10

Hospital Operations 393 156 16 2

Facilities and Development 32 9 3 0

Corporate

328 102 8 4

Acute and Emergency Medical Division 1,088 313 65 31

Director Hospital Services

82 11 1 0

Mental Health and Addiction Services

1,013 261 32 4

Sub Specialty Medicine and Health of Older People 769 174 43 6

Waitemata DHB Governance and Funding

80 16 6 2

Total (February 2018) 5,682 1,526 262 85

Comparison – February 2017 5,537 1,483 287 74

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Staff Turnover Rates have remained stable and within the upper limit at an organisational level since the last reporting period. CWF is reporting at 13.2% and trend reporting shows a slight increase each month since November 2016 mainly impacting Maternity Services and ARDS. Within the range of activities underway to address turnover the service is focussing closely on analysis of the impact of internal transfers on turnover and exit interview feedback to identify trends and opportunities. Clinical coaches have been introduced in both Divisions to support new graduate retention. Acute and Emergency Division report the highest variance turnover rates and variance against upper tolerance level, although this eases slightly in March. Continued review of exit data does not indicate trends or particular issues with a general range of issues being noted as reasons for exiting.

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Divisional Reports

Acute and Emergency Medicine Division Service Overview This division is responsible for the provision of General, Acute and Emergency Medical services. The division includes the departments of General Medicine, Assessment and Diagnostic Unit (ADU), Assessment, Diagnostic and Cardiology Unit (ADCU), Emergency Medicine, Cardiology, Medical wards and Hyperbaric Medicine. The service is managed by Dr Gerard de Jong (Division Head) and Alex Boersma (General Manager); Head of Division Nursing is Shirley Ross. The Clinical Directors are Dr Hamish Hart for General Medicine, Dr Willem Landman for Emergency Care, Dr Tony Scott for Cardiology, Dr Hasan Bhally and Dr Hugh de Lautour for ADU and ADCU and Dr Chris Sames for Hyperbaric Medicine.

Highlight of the Month Chest Pain Clinic Wait time under six weeks against a target of 80% The recommended wait time for the non-urgent Cardiology Chest Pain clinic is 80% of patients seen within six weeks of being referred. The Waitemata Cardiology Chest Pain outpatient clinic has historically struggled to achieve this target; however over the last four months the target has been consistently achieved and is at 94% in March 2018. The current median waiting time for the Chest Pain clinic is 15 days. Cardiology capacity planning predictions indicate that this performance will be sustained. In addition over the last 12 months the service have worked their way through a backlog of patients on the waiting list reducing the waiting list from over 600 patients in April 2017 to 130 patients in March 2018. An analysis of the patients referred to the Chest Pain clinic shows that Waitemata DHB has the highest referral rate of outpatient chest pain in the northern region and approximately 40 patients are added to the outpatient Chest Pain clinic waiting list on a weekly basis. Demand management strategies have included the creation of nurse led and doctor led Exercise Tolerance Test clinics, where the patient has a consultation and an excercise tolerance test during the same clinic visit and we are working to understand and manage on-going referrals, particularly from the ED and work on the acute chest pain pathway will assist with this.

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Key Issues Choosing Wisely Campaign in the EDs Choosing Wisely is an international campaign that seeks to advance a dialogue for avoiding unnecessary medical tests, treatments and procedures. It aims to identify commonly performed interventions with limited evidence or benefit and to reduce the unintended harm caused by medical care. It is an initiative that started in the United States of America and has now spread across the globe as more countries recognise the value of encouraging both patients and clinicians to engage in conversations about unnecessary tests, treatments and procedures. A report released in April 2017 has found that up to 30% of selected medical tests, treatments and procedures are potentially unnecessary. This leads to significant waste in terms of patients’ time, system resources and costs while also leading to increased wait times and patient harm. Choosing Wisely New Zealand was launched in December 2016 and is being led by the Council of Medical Colleges in partnership with a range of organisations including the Health Quality and Safety Commission and Consumer New Zealand. The Waitemata DHB EDs have been using Choosing Wisely evidence-based recommendations to design new processes in the ED, incorporating them into the ED bundles of care. Current data trends demonstrate that there is a large number of unnecessary urine tests conducted (both point of care and via the laboratory) for patients presenting to the ED with urinary tract symptoms. This unnecessary testing does not improve patient health outcomes and has a significant financial impact on the health system. Mid-stream urine testing for urinary tract infections is the most frequently requested microbiology test at Waitemata DHB. Poor quality urine sampling and unnecessary testing leads to inaccurate diagnosis and treatment of urinary symptoms. The ED wanted to improve patients experience and outcomes by creating a lean end to end process for mid-stream urine testing aligned to best practice and improve the quality of sampling to reduce the need for retesting. Patients were classified into two defined streams – complex or non-complex and new pathways were developed with a reduced testing requirement. The ED improved sample quality and reduced repeat samples by putting posters explaining how to do a mid-stream urine sample in the ED patient toilets. We anticipate being able to reduce laboratory samples by 60% and point of care urine sampling by 43%. For non-complex patients, treatment is determined by the point of care test and in complex patients the point of care testing was eliminated in preference to a laboratory test. The annual financial benefit is projected to be in excess of $200,000 with additional soft savings including a reduction in clinician time.

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Scorecard – Acute and Emergency Medicine Division

Actual Target Trend Waiting Times Actual Target Trenda. Shorter Waits in ED 96% 95% ADU - % seen from triage w/in 120 mins 68% 85%

Elective coronary angiography w/in 90 days 100% 95%

Angiography for ACS w/in 72 hours 71% 70% b. Chest pain clinic wait time under 6 weeks 90% 80%

Patient Experience Actual Target Trend b. O/P Transthoracic Echo wait time under 12 weeks 55% 95%

Complaint Average Response Time 11 days


Service Delivery ADU % seen from triage within 120 minutes – 68% against a target of 85%

General Medicine – In February 2018, 65% of NSH General Medicine patients were seen within 120 minutes of arrival time (as per the graph below). Resident Medical Officer (RMO) rosters in General Medicine are not currently aligned to peak patient presentation times with staffing higher over the morning shift and decreasing significantly after 4pm. This is the area of focus for on-going work in the ADU and in the registrar rosters which are currently under development. In the new roster we aim to smooth out the number of doctors clerking in medicine to provide more balance across the day.

Source - Acute Specialties Report Plus ADU

Surgery – In February 2018 53% of surgical patients were seen within two hours of triage.

Orthopaedics – In February 2018 44% of patients seen within two hours of triage. O/P Transthoracic ECHO wait time under 12 weeks – 55% against a target of 95% This is a steady improvement over previous months and we shall continue to work on the ECHO target. This target will continue to be challenging due to the volume of referrals received. A review of the trends in demand is being undertaken over the next month. Transthoracic Echocardiography (TTE) has unparalleled advantages over other cardiac diagnostic tools such as electrocardiography, CT and MRI. Specifically, its portability and safety, and the ability for real-time analysis of ultrasound images make it ideal for point of care screening. We are in the process of developing a business case for a Cardiac Screening service. A rapid screening service will classify the risk of patients to ensure that the right care is provided in a timely manner. It will incorporate an Electro-Cardiograph (ECG) and a scout TTE (sTTE) and it is anticipated that it will allow earlier identification of patients with high risk or pathology and will decrease unnecessary referrals. This will potentially decrease wait times for TTE and improve the time and cost effectiveness of the service being delivered.

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The productivity within Cardiology 2D ECHO has improved over time with a decrease in the waiting list of 19% since November 2017. However, with an increase in clinical demand for ECHOs our challenge is to keep up with the reporting of these ECHOs in a timely manner. We have implemented a number of strategies to increase reporting capacity and manage triage and clinical priority.


Shorter Stays in Emergency Departments

1. Analyse ED mental health attendances to understand the profile of presentations – June 2018.

2. Work with Mental Health to develop clinical and shared care pathways for regular and high users of ED with plans developed for known service users of Specialist Mental Health services – March 2018.

3. Implement shared care Mental Health pathways – June 2018.

4. Formalise the use of primary options for acute care in the ED develop and implement a range of pathways – March 2018.

5. Implement the OptimisED project in Waitakere ED to effectively utilising new ED areas to maximise patient flow – June 2018.

6. Continue to work with urgent care/primary care partners to improve access to primary care for primary care issues – June 2018.

7. Promote access afterhours to reduce low acuity presentations – December 2017.

8. Develop a pilot in Waitakere ED to more efficiently assess the low acuity patients – June 2018.

Delivery of Regional Service Plan

Cardiac Services – ACS

9. Audit compliance with the current pathway and the Timi assessment criteria/process – December 2017.

10. Audit the appropriate referral pathway for exercise tolerance test (ETT) – December 2017.

11. Audit the rate of negative vs. positive ETTs to inform this work – December 2017

Cardiac Services – Heart Failure

12. Audit all patients with a first diagnosis of heart failure to track their readmission rates – December 2017.

13. Engage in the regional process via the regional cardiac network to agree protocols, guidance, processes and systems to ensure optimal management of patients with heart failure – June 2018.


All areas on track.

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Financial Results - Acute and Emergency Medicine

($000’s)


REVENUE

* Government and Crown Agency 217 236 (19) 2,056 2,047 8 3,075

Other Income 62 43 19 494 370 124 556

Total Revenue 279 279 0 2,550 2,417 132 3,631

EXPENDITURE

Personnel

Medical 3,755 3,541 (214) 30,288 28,712 (1,576) 44,601

Nursing 5,584 5,190 (395) 44,467 44,184 (283) 68,092

Allied Health 197 202 5 1,616 1,681 65 2,571

Support 0 1 1 0 10 10 16

Management / Administration 559 552 (8) 4,652 4,481 (171) 6,926

Outsourced Personnel 100 92 (8) 702 735 33 1,136

10,195 9,578 (617) 81,725 79,804 (1,922) 123,342

Other Expenditure

Outsourced Services 17 44 28 302 385 83 578

Clinical Supplies 1,128 1,085 (43) 9,785 9,746 (39) 14,880

Infrastructure & Non-Clinical Supplies 313 155 (159) 2,789 2,536 (254) 3,370

1,458 1,284 (174) 12,876 12,667 (209) 18,827

Total Expenditure 11,653 10,862 (791) 94,601 92,471 (2,131) 142,169

Cost Net of Other Revenue (11,375) (10,583) (791) (92,052) (90,053) (1,998) (138,538)


* Government and Crow n Agency : Includes MoH direct revenue, ACC and CTA revenue. Excludes PBFF revenue.


Acute and Emergency Medicine - February 2018

Comment on major financial variances The overall result for Acute and Emergency Medicine was $791k unfavourable for February and $1,998k unfavourable for the YTD. The YTD Acute Non-IDF WIES volumes were 5.4% above contracted volumes and Elective Non-IDF WIES were 3.9% above contract. The notional additional revenue if funded would have been $5,827k YTD for the Acute Non-IDF WIES volumes and $145k YTD for the Elective Non-IDF WIES volumes. Revenue (On budget for February, $132k favourable YTD) The break even February result was due to increased university revenue offset by reduced ACC revenue. The favourable YTD variance was due to increased university training revenue. Expenditure ($791k unfavourable for February, $2,131k unfavourable YTD) The unfavourable variance for February was due to a $402k transfer of the January bed closure efficiencies in Wards 6, 11 and Anawhata to the Director of Hospital Services division, $150k of unrealised expenditure reduction initiatives and $176k of increased costs for Registrars due to over allocations, pricing variations and increased allowances. Personnel ($1,922k unfavourable YTD) Medical ($1,576k unfavourable YTD) The unfavourable variance was due to $1,579k of expenditure increases for Registrars and House Officers, as a result of unbudgeted over allocations, pricing variations and additional allowance costs. The strategies for

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reducing expenditure over the balance of the year will continue to focus on maximising annual leave and the ongoing implementation of the TransforMED ‘Home Warding’ initiative. Nursing ($283k unfavourable YTD) The unfavourable position was due to $503k of additional expenditure in both the NSH and WTH EDs arising from high staff turnover levels and the subsequent pressures on overtime and orientation expenses. The Patient Attendance (Watch) responsibility centre was favourable by $150k due to vacancies. The balance of the year result is expected to benefit from the closure of 12 beds on Ward 11. Opportunistic benefits through flexing beds closed are being realised and continue to be expected through the remainder of the year. Allied Health ($65k favourable YTD) The favourable variance was due to vacancies within Cardiology. The favourable position will continue through the balance of the year. Support and Management/Administration ($161k unfavourable YTD) The unfavourable variance was due to pricing variations in the EDs and unbudgeted roles within Patient Care and Access. Outsourced Personnel ($33k favourable YTD) The favourable variance was due to a reduced need for locum cover. Other Expenditure ($209k unfavourable YTD) Outsourced Services ($83k favourable YTD) The favourable variance was due to lower laboratory and pathology expenditure. Clinical Supplies ($39k unfavourable YTD) The unfavourable variance was due to $119k of increased expenditure on patient appliances and $97k of increased patient consumable expenditure offset by $197k of reduced expenditure on cardiology implants. Infrastructure and Non-Clinical Supplies ($254k unfavourable YTD) Printing, stationery and office expenses were $165k favourable and security services were $58k favourable, this was predominantly in the Wards and the EDs. The favourable variances have been offset by a $483k expenditure reduction target that has not been realised. Getting back on track initiatives The TransforMED and ADUcare initiatives continue to show positive results. The ‘Home Warding’ pilot has been expanded to all medical wards atNSH. These initiatives have combined to improve patient flow and shorten the average length of stay at NSH by 18% since inception. The fiscal benefit is being realised through the Flexed Bed programme and our ability to close beds. The YTD value of bed savings transferred to the Hospital Services provider savings line is $1,063k. Continued emphasis will be placed on ensuring appropriate annual leave consumption as well maintaining control over headcount levels.

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Specialty Medicine and Health of Older People Division

Service Overview This Division is responsible for the provision of medical sub-specialty and health of older people services. This includes respiratory, renal, endocrinology, stroke, dermatology, haematology, diabetes, rheumatology, infectious diseases, medical oncology, neurology, gastroenterology, smoke-free, fracture liaison services and Older Adults and Home Health, which in turn includes palliative care, geriatric medicine, district nursing, EDARS (early discharge and rehabilitation service), needs assessment and service coordination, the specialist gerontology nursing service Nga Kaitiaki Kaumatua, Mental Health Services for Older Adults, and the AT&R wards. The division also includes the Medicine patient service centre. Allied Health provides clinical support (inpatient, outpatient and community) across the Acute and Emergency Medicine Division, Specialty Medicine and Health of Older People Division and Surgical and Ambulatory Service and reports to the General Manager Specialty Medicine and Health of Older People.

The service is managed by Dr John Scott (Head of Division) and Brian Millen (General Manager). The Clinical Directors are Dr Cheryl Johnson for Geriatric Medicine, Dr Sachin Jauhari for Psychiatry for the Older Adult, Dr Stephen Burmeister for Gastroenterology, Dr Simon Young for Diabetes/Endocrinology, Dr Janak De Zoysa for Renal, Dr Megan Cornere for Respiratory, Dr Ross Henderson for Haematology, Dr Blair Wood for Dermatology and Dr Michael Corkill for Rheumatology. The Clinical Director for Palliative Care is currently vacant.

Highlight of the Month Type 2 Diabetes: Supporting people and their families living with poorly controlled type 2 diabetes to be ‘leading partners’ in their own care. Diabetes is a long-term condition with high morbidity and mortality that affects more than 26,000 people living in the Waitemata DHB catchment. It is estimated that the population living with diabetes is increasing by 7% per annum. Type 1 diabetes is characterised by a younger age of onset and a predominant need for insulin therapy. Type 2 diabetes, which accounts for about 90% of cases, is characterised by a (usually) older age of onset and a strong association with other risk factors for chronic disease, such as smoking, overweight and lack of exercise. The diabetes service at Waitemata DHB has a multidisciplinary team approach provided by Endocrinologists (Diabetologists), Clinical Nurse Specialists (CNS), Dietitians, Podiatrists, a Health Psychologist, and Ophthalmologists (the latter under a contract with Auckland DHB). Most clinics are undertaken in a formal outpatient setting on a one to one basis. Type 1 patients generally require intensive intervention for the first year or two and intermittent follow-up for the rest of their lives. Health care utilisation by individuals with type 2 diabetes varies greatly depending on how well the disease is managed. In addition to medical care, effective treatment for type 2 diabetes requires behavioural modifications. In turn, successful and enduring changes in lifestyle behaviours (such as smoking diet and exercise) work best when the person with diabetes adopts a self-management approach in partnership with health services. While behavioral changes can be challenging to achieve, people with Type 2 diabetes who successfully make the required changes have a greatly reduced requirement for medical therapy, greatly reduced incidences of complications, and a greatly increased quality of life Historically the Waitemata DHB diabetes service has favoured a model of care whereby people remained under the care of specialist nurses in the service indefinitely and were encouraged and educated to be able to better manage their diabetes. Progress was monitored at 3, 6 or 12 monthly outpatient visits. Unfortunately, poor

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adherence to lifestyle interventions was widespread, particularly over the longer term, and it was not uncommon for people to leave appointments relatively motivated only to return some months down the line with little or no progress to report. Following an audit of ‘planned’ appointments mid 2017 the service asked two fundamental questions:

1. How might we support people and their families living with poorly controlled type 2 diabetes to be ‘leading partners’ in their own care?

2. How might Waitemata DHB’s diabetes services better align to consumer and provider needs? The outcome was a new model of care whereby individuals are more personally involved in an unified, holistic planning process that encourages them to express their needs and decide on their own priorities. They have the opportunity to work through a process of information-sharing, shared decision-making and action planning with a specialist nurse, dietitian and a psychologist and receive input from a consultant physician as required.

Encompassing all of this was the decision to move to a tailored ‘package’ of supported multidisciplinary care delivered over a shorter timeframe. While not directly related to the ‘future diabetes system of care’ work being undertaken by the regional Diabetes Service Level Alliance (DSLA) the new model is well aligned to its underlying strategic principles, namely:

People living with diabetes have a good understanding of the actions they can take to prevent diabetes related complications and have the right tools and support to take these actions.

Services are configured around the needs of people with diabetes and are genuinely oriented around meeting the needs of people with diabetes in a way that is respectful and effective.

Appointments 1-3 are scheduled fortnightly with subsequent appointments at 1-2 month intervals. This level of engagement continues until patients have the knowledge, skills and ability to manage their diabetes effectively in the context of their everyday life – this has typically been five to six appointments.

Rather than taking a role as the “constant supervisor” of the person with diabetes, our new model of care encourages supported autonomy and assumes that people are most likely to make the required behavioural changes if they are given an intensive package early on in their management.

Following this phase, people can be returned to primary care, which is viewed as the “medical home” for chronic disease management. If in the future the person requires a review by a specialist or intervention from one of the other diabetes team members then primary care will initiate a new referral, and the person can be assessed for the new issue. In summary, our hope is that this new approach will enable the service to focus its efforts on:

Intensive support and lifestyle modification for people with new diagnoses,

Ongoing care of the highly complex,

As-required review of other patients if and when a problem occurs,

Supporting primary care, which is where the bulk of the management work for non-complex chronic disease occurs.

The new model was introduced late 2017 and while no formal outcome data is available at this early stage the clinical team report that patients are engaging well and agreeable to the frequency of appointments. They feel that patients are better able to maintain motivation, are achieving goals, and appreciative of the opportunity to explore barriers in a timely way. The team regard the new model as a much more professionally satisfying way to work. Feedback from patients lends support to this view. For example:

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James, a 44 year old male with a long history of poorly controlled diabetes and severe eye disease reluctantly accepted a referral to the service by his General Practitioner. James had been prescribed medication by his General Practitioner but had not been taking it. James felt his General Practitioner just kept giving him pills that he could not afford and that no one really explained why or listened to his concerns. After three appointments James told the clinical team that he “had faith that something was happening to improve his health”. James said that he “likes that he plays a part in working towards his goals and feels more in control.” He found the frequency of the appointments difficult around work at times, but is committed to attending as he can see progress. Amin, a 63 year old male, was referred to the service in 2016 and was attending clinic on average every three months. Despite his regular attendance Amin had not managed to bring his diabetes under control. He transitioned to the new model in early February 2018 and was discharged from the service in April having successfully achieved his target blood glucose level. Amin said that he “really liked seeing the Clinical Nurse Specialist regularly because it gave him a reason to work on what he needed” and that he was “able to get feedback and do another plan to keep moving forward toward a goal.” A full evaluation of the new model will be undertaken in late 2018.

Key Issue Reducing Inequalities Significant gains have been made but there is still some work to do in reducing inequalities in clinic Did Not Attend (DNA) rates. Historically our process for managing outpatient appointment was to waitlist the referral, book anything urgent within 1-2 weeks and work through the remainder with a view to ensuring everyone had the opportunity to attend within the required four months. All non-urgent appointments were arranged by sending letters to patients advising them when and where to come. We did not routinely check with the patient if they were able to attend on the given day. Some attended, some called in to reschedule (often at the last minute) and some simply did not attend. Generally the process was repeated for those in the latter group in the belief that they may not have received the appointment letter or had been unable to attend on the specific date. In March 2017, the division of Medicine introduced patient focused booking (PFB) for first specialist appointments. PFB had been identified in the ‘Auckland and Waitemata DHB joint DNA Strategy July 2016’ paper as a “high impact” initiative for reducing non-attendance in clinic.

PBF puts patients at the heart of the booking process by engaging them in dialogue about their appointment. With PFB, patients are sent a referral acknowledgment letter, indicating the likely wait for their appointment and explaining that they are on a waiting list (non-routine patients are clinically prioritised to by-pass this process and will always be seen first). As the patient nears the top of the waiting list, they receive a further letter inviting them to telephone and arrange an appointment. The process is complemented by a policy that prevents a clinic being cancelled with less than six weeks' notice. Therefore, when the patient phones, the appointment options are limited to only those clinics scheduled in the next few weeks. The booking clerk offers a choice of dates and times and the patient chooses the most convenient to them. If the patient fails to phone the booking clerk will attempt to call the patient on three occasions having checked with the General Practitioner that contact details are current and correct. If they are unable to make contact a further letter is sent to the patient and their General Practitioner, explaining that they have been removed from the waiting list. One year on and there have been some significant reductions in DNA rates for first specialist appointments. Across all ethnicities DNA rates dropped from 10.3% in March 2017 to 7.8% in March 2018. The benefit of PBF appears to have been greatest in our Maori and Pacific patients with Maori DNA rates dropping from 23.4% to 18.3% and Pacific 24.2% to 18.1% (table one). Whilst these improvements are to be welcomed they suggest that more work will need to be done to further reduce inequalities in clinic DNA rates.

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Table one

Scorecard – Specialty Medicine and Health of Older People Services

Patient Experience Actual Target Trend Waiting Times Actual Target TrendComplaint Average Response Time 6 days



Better Help for Smokers to Quit Health Target

1. Produce reporting by ethnicity for Smoking Status, Brief Advice and Cessation Support for priority healthcare settings (Hospital population) – January 2018.

2. Improve data entry and IT tools to improve reporting of Brief Advice and Cessation Support in priority healthcare settings (e-vitals, hospital only) – June 2018.

Bowel Screening

Access across all endoscopy services 3. Recruit two nurses with full 5-day week coverage to ensure timely access for high priority

(P1) patients – September 2017.

4. Develop an annual production plan for all endoscopy procedures to enable weekly performance tracking – in place by July 2017.

5. Recruit to the two endoscopy fellow roles – December 2017.

6. CNS endoscopist role in place – December 2017.

7. Regional collaboration, through a contractual arrangement, to improve access and timeliness to colonoscopy procedures. Work with Auckland DHB through an outsourcing arrangement to do weekly lists for Waitemata DHB patients – July 2017.

Delivery of Regional Service Plan

Stroke

8. Ensure all Allied Health and Nursing staff in In-Patient Rehabilitation and Community Rehabilitation services complete a stroke competency training programme within the first year of employment – ongoing.

9. Support a range of health professionals working in stroke care to attend the Stroke Society of Australasia’s annual conference - August 2017.

Hepatitis C

10. Support the roll-out of the integrated Hepatitis C service across the region including GP practice support, raising awareness, extending services and monitoring progress – over 2017/18.


6. Clinical Nurse Specialist Endoscopist role in place – December 2017: This is still in progress. A budget bid will be required, which has yet to be approved. The Nurse that planned to employ for this role is also currently on maternity leave and is expected to back around March 2018. She has, however, started her papers with The University of Auckland from January 2018.

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Financial Results – Specialty Medicine and Health of Older People

($000’s)


REVENUE

* Government and Crown Agency 624 572 52 4,938 4,962 (23) 7,455

Other Income 47 104 (57) 619 905 (286) 1,358

Total Revenue 671 676 (5) 5,557 5,867 (309) 8,814

EXPENDITURE

Personnel

Medical 1,580 1,572 (9) 13,266 13,160 (107) 20,761

Nursing 2,250 2,132 (118) 17,837 17,411 (426) 27,250

Allied Health 1,521 1,380 (141) 12,922 13,359 438 20,235

Support 0 0 0 0 0 0 0

Management / Administration 422 418 (4) 3,597 3,629 33 5,608

Outsourced Personnel 44 48 4 447 416 (30) 623

5,817 5,549 (267) 48,068 47,976 (92) 74,479

Other Expenditure

Outsourced Services 339 201 (139) 2,768 1,799 (969) 2,673

Clinical Supplies 941 835 (106) 8,243 7,203 (1,040) 10,940

Infrastructure & Non-Clinical Supplies 196 (61) (257) 1,755 840 (915) 890

1,476 975 (501) 12,767 9,843 (2,924) 14,503

Total Expenditure 7,293 6,524 (769) 60,835 57,819 (3,016) 88,982

Cost Net of Other Revenue (6,622) (5,848) (774) (55,277) (51,952) (3,325) (80,168)


* Government and Crown Agency : Includes MoH direct revenue, ACC and CTA revenue. Excludes PBFF revenue.


Specialty Medicine and HOPS - February 2018

Comment on major financial variances The overall result for Specialty Medicine and Health of Older People was $774k unfavourable for February and $3,325k unfavourable for the YTD. Revenue ($5k unfavourable for February, $309k unfavourable YTD) The YTD unfavourable variance was due to outsourced gastroscopy services $565k contracted directly by the Funder, offset by ACC revenue of $348k YTD. Expenditure ($769k unfavourable for February, $3,016k unfavourable YTD) The unfavourable variance for February was due to $204k of unbudgeted outsourced gastroscopy services, $302k of unrealised expenditure reduction initiatives, $100k of budget phasing within Allied Health and $53k of additional client related expenditure on high level community care for complex needs patients. Costs within the Kingsley Mortimer Unit were $99k unfavourable due to an increase in patient watches and nurses off work on paid leave.

Personnel ($92k unfavourable YTD) Medical ($107k unfavourable YTD) The unfavourable variance was due to sabbatical cover and Infectious Diseases SMO expenditure.

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Nursing ($426k unfavourable YTD) The unfavourable variance was due to increased patient watch costs of $188k in the Kingsley Mortimer Unit and unrealised expenditure reduction initiatives.

Allied Health ($438k favourable YTD) The favourable variance was due to vacancies within the Allied Health, Needs Assessment Service Centre and Renal services.

Support and Management/Administration ($33k favourable YTD) The favourable variance was due to vacancies within Haematology Research.

Outsourced Personnel ($30k unfavourable YTD) The unfavourable variance was due to increased patient watch costs in the KMU.

Other Expenditure ($2,924k unfavourable YTD) Outsourced Services ($969k unfavourable YTD) The unfavourable variance was due to $1,269k of unbudgeted gastroscopy procedures outsourced to Auckland DHB and Waitemata Endoscopy offset by a $282k favourable position within Needs Assessment Service Centre respite.

Clinical Supplies ($1,040k unfavourable YTD) The unfavourable variance was due to $570k of increased expenditure on high level respite care for complex needs patients within the Mental Health of Older Adults service, $158k of unrealised expenditure reduction initiatives, $101k on mobility aids within the Allied Health service and $82k of treatment disposables within the Home Health service.

Infrastructure and Non-Clinical Supplies ($915k unfavourable YTD) The unfavourable variance was due to unrealised expenditure reduction initiatives.

Getting back on track initiatives The service is concentrating on maximising leave consumption, recruiting to cover vacancies instead of using overtime and external bureau, and flexing staffing levels with reduced bed demand where appropriate in conjunction with improved flow initiatives. The most significant financial pressure to the division is outsourced gastroscopies and colonoscopies, which has cost $1,834k YTD. This is being mitigated in part by using two lists of internal resource from the Bowel Screening Programme in the remainder of the year.

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Child, Women and Family Services

Service Overview This Division is responsible for the provision of maternity, obstetrics, gynaecology and paediatric medicine services for our community, for the regional Out of Home Children’s Respite Service, the Auckland Regional Dental Service (ARDS), and the national Child Rehabilitation Service. Services are provided within our hospitals, including births, outpatient clinics and gynaecology surgery, and within our community, e.g. community midwifery, mobile/transportable dental clinics and the Wilson Centre. The service is managed by Dr Meia Schmidt-Uili (Division Head) and Stephanie Doe (General Manager). H

Documents

HOSPITAL ADVISORY COMMITTEE (HAC) MEETING · ZW ] v v tZvµ v ^ v v t ] ]}vW }P uu .[ The Committee Chair acknowledged the presentation and noted the complexity of the programme