countiesmanukau.health.nz · 2020. 9. 2. · Vui Mark Gosche - CMDHB Chair . Colleen Brown –...

Counties Manukau District Health Board – Hospital Advisory Committee 9 September 2020

HOSPITAL ADVISORY COMMITTEE (HAC) MEETING 09 September 2020

Venue: Middlemore Hospital – Executive Meeting Room 1

Level 1 Bray, Executive Management Offices 100 Hospital Road, Otahuhu, Auckland

Time: 1.00 pm

Committee Members Catherine Abel-Pattinson – HAC Chair Dr Lana Perese – HAC Deputy Chair Vui Mark Gosche - CMDHB Chair Colleen Brown – CMDHB Board Member Dianne Glenn – CMDHB Board Member Garry Boles – CMDHB Board Member Katrina Bungard – CMDHB Board Member Paul Young – CMDHB Board Member Apulu Reece Autagavaia – CMDHB Board Member Tipa Mahuta – CMDHB Board Member Barry Bublitz – Mana Whanua Robert Clark – Mana Whenua Brittany Stanley-Wishart (Observer) Tori Ngataki (Observer)

CMDHB Management Avinesh Anand – Deputy CFO Provider Chris Mallon – Chief Midwife Dr Jenny Parr – Chief Nurse and Director of Patient and Whaanau Experience Jessica Ibrahim - Executive Advisor, CEO’s Office

Dr Kate Yang – Funder Manager, Hospital Mary Burr – General Manager Women’s Health Dr Mary Seddon – Director Ko Awatea Dr Peter Watson – Chief Medical Officer Sanjoy Nand – Chief of Allied Health, Scientific & Technical Professions Teresa Opai – Secretariat

PART I – Items to be Considered in Public Meeting

1.00 pm 1. COMMITTEE ONLY SESSION Page

1.30 pm 2. AGENDA ORDER AND TIMING 1 2.1 Apologies/Attendance Schedule

2.2 Disclosed Interests 2.3 Specific Interests

3 4 6

3. CONFIRMATION OF MINUTES

1.35 pm 1.40 pm

3.1 Minutes of the Hospital Advisory Committee Meeting – 12 August 2020 3.2 Action Items Register

7 16

4. PROVIDER ARM PERFORMANCE REPORTS

1.45 pm 1.55 pm 2.00 pm

4.1 Executive Summary (Mary Burr) 4.2 Financial Results – CMDHB Provider Arm (Avinesh Anand) 4.3 Provider Volumes Report (Kate Yang)

20 36 38


5. CORPORATE REPORTS Page

2.05 pm 2.10 pm 2.15 pm 2.25 pm 2.45 pm 3.05 pm 3.15 pm

5.1 Update: Future Integrated Cancer Clinic Opportunities - Presentation (Dr Jon Mathy) 5.2 Patient Flow - Every Hour Counts Quarterly Update (Dr Mary Seddon) 5.3 Virtual Site Tour: Manukau Super Clinic – (Dr John Kenealy, Pauline McGrath) 5.4 Strategic Deep Dive: Disability Services (Sanjoy Nand) 5.5 Operational Deep Dive: Maaori and Pacific Health (Sharon McCook, Doana Fatuleai) 5.6 Human Resources Quarterly Report (Elizabeth Jeffs) 5.7 Staff Survey Results - Presentation (Elizabeth Jeffs)

40

48

3.25 pm 6. INFORMATION ONLY

6.1 Cancer Control Agency Impact of Covid on Cancer Services - Report 3 August 2020 6.2 Capturing Patient and Whaanau Experience – Approaches in CM Health

63 106

3.25 pm 7. RESOLUTION TO EXCLUDE THE PUBLIC 135

Counties Manukau District Health Board - Hospital Advisory Committee 9 September 2020

BOARD MEMBER ATTENDANCE SCHEDULE – HAC 2020

Name Jan 26 Feb Mar 08 Apr 27 May Jun 01 Jul 12 Aug 09 Sep Oct 04 Nov 16 Dec

Catherine Abel-Pattinson

No

Mee

ting

No

Mee

ting

* *

No

Mee

ting

*

No

Mee

ting

Colleen Brown * * * *

Dianne Glenn * * * *

Garry Boles x x x x x

Katrina Bungard * * * *

Lana Perese * * * *

Paul Young * x * *

Reece Autagavaia * x * *

Tipa Mahuta * * * *

Barry Bublitz x * x * x

Robert Clark x * * *

Mark Gosche x * * * *

Brittany Stanley-Wishart x

Tori Ngataki *

* Via video conference call

Counties Manukau District Health Board 9 September 2020

HOSPITAL ADVISORY COMMITTEE DISCLOSURE OF INTERESTS

9 September 2020 Member Disclosure of Interest

Catherine Abel-Pattinson (Chair) • Board Member, healthAlliance NZ Limited. • Board Member, CMDHB; Chair, Hospital Advisor Committee;

Member, Audit & Risk Committee • Member, NZ Nurses Organisation (previous Board member) • Member, Directors Institute • Board Member, IAN - International Accreditation NZ • Husband (John Abel-Pattinson):

o Director, Blackstone Group Limited o Director and Shareholder, Blackstone Partners Limited o Director, Blackstone Treasury Limited o Director, Bspoke Group Limited o Director, Barclay Management (2013) Limited o Director, AZNAC (JAP) Limited o Director, Chatham Management Limited o Director, MAFV Limited o Director, Wolfe No. 1 Limited o Director, 540 Great South Motels Limited o Director, Silverstone Property Group Limited o Director, various single purpose property owning companies o Director and Shareholder, various Trustee Companies related

to shareholding in the above

Lana Perese (Deputy Chair) • Director & Shareholder, Malatest International & Consulting • Director, Emerge Aotearoa Limited Trust • Trustee, Emerge Aotearoa Housing Turst • Director, Vaka Tautua • Director, Malologa Trust

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

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

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

Counties Manukau District Health Board 9 September 2020

Dianne Glenn • Member, NZ Institute of Directors

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

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

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

Garry Boles • Member, C and R

• NZ Police Constable

Katrina Bungard

• Chairperson MECOSS – Manukau East Council of Social Services. • Elected Member, Howick Local Board • Deputy Chair, Amputee Society Auckland/Northland • Member of Parafed disability sports • Member of NZ National Party

Paul Young • TBC

Reece Autagavaia • Member, Pacific Lawyers’ Association • Member, Labour Party • Trustee, Epiphany Pacific Trust • Trustee, The Good The Bad Trust • Member, Otara-Papatoetoe Local Board • Member, Pacific Advisory Group for Mapu Maia – Problem

Gambling Foundation • Board of Trustees Member, Holy Cross School • Member of the Cadastral Surveyors Board • Assessor of the Creative Communities Scheme South & East

Auckland

Tipa Mahuta • Deputy Chair, Te Whakakitenga o Waikato • Councillor, Waikato Regional Council


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 9 September 2020 Director having interest Interest in Particulars of interest Disclosure date Board Action Catherine Abel-Pattinson Whaanau Accommodation

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

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

Counties Manukau District Health Board – Hospital Advisory Committee – Public 12 August 2020

Minutes of Counties Manukau District Health Board Hospital Advisory Committee

Held on 12 August 2020 at 1.00pm Exec MR 1 Bray Building, Middlemore Hospital

100 Hospital Road, Otahuhu, Auckland and via Zoom - https://cmhealth.zoom.us/j/94562862330

PART I – Items Considered in Public Meeting BOARD MEMBERS PRESENT

Catherine Abel-Pattinson (Chair) Dr Lana Perese (Deputy Chair) Vui Mark Gosche (DHB Chair) Colleen Brown Dianne Glenn Katrina Bungard Paul Young Apulu Reece Autagavaia Tipa Mahuta Robert Clark (joined 2.26 pm) Tori Ngataki (Observer)

ALSO PRESENT Avinesh Anand (Deputy CFO, Provider) Jess Ibrahim (Executive Advisor, CEO’s Office) Karyn Sangster (Acting Chief Nurse) Dr Kate Yang (Funder Manager) Mary Burr (General Manager Women’s Health via Zoom) Dr Mary Seddon (Director Ko Awatea) Sanjoy Nand (Chief of Allied Health, Scientific & Technical Professions) Teresa Opai (Secretariat) (Staff members who attended for a particular item are named at the start of their item)

PUBLIC PRESENT

No members of the public were present. 1. COMMITTEE ONLY SESSION

The Committee only session commenced at 1.00 pm. The DHB Management team joined the meeting at 1.34pm. Apulu Autagavaia opened the meeting with a prayer.

2. AGENDA ORDER AND TIMING Agenda items were taken in the same order through to and including item 3.2.1, then moved to item 4.1, returned to item 3.2.2, moved to item 4.2, moved to item 5.2, returned to item 5.1, moved to item 5.4, item 5.5, returned to item 5.3 and followed the remainder of the agenda in order.

https://cmhealth.zoom.us/j/94562862330


2.1 Apologies/Attendance Schedule Committee: Barry Bublitz, Garry Boles, Brittany Stanley-Wishart DHB: Chris Mallon, Dr Jenny Parr, Dr Peter Watson

2.2 Disclosed Interests Apulu Autagavaia advised pre-meeting that he is no longer a member of the district licensing committee of Auckland Council. Action: Secretariat to update Disclosed Interests register to reflect the change noted above.

2.3 Special Interests There were no Special Interests to note requiring update.

3. CONFIRMATION OF MINUTES 3.1 Minutes of the Hospital Advisory Committee Meeting – 1 July 2020

Ms Glenn advised that the link provided to access the virtual tour of MMC was not working. Action: Secretariat to check link and advise outcome.

Note: post meeting the provided link was checked and is working correctly. Whilst the agenda item for this video was noted as being a virtual tour of MMC, it is in fact focussed on the Incident Management Team based at MMC.

Resolution (Moved: Ms Brown/Seconded: Ms Bungard) That the Minutes of the Hospital Advisory Committee held on 1 July 2020 be approved.

Carried

3.2 Action Items Register – Public

Noted with additional comments below. 3.2.1 Learnings from Neonatal Audit (Mary Burr)

Ms Burr provided a verbal update to the meeting. Key points: • Births in April were at a similar level as the preceding months, gestational age was the same as

in April and there were slightly fewer younger babies born (less than 36 weeks) but this did not account for the 30% fewer admissions. Work continues with colleagues nationally and regionally to identify the cause of the variance.

Ms Glenn requested a further update be provided when information becomes available. Action: A further update is to be provided by Ms Burr when information becomes available.

3.2.2 Reported Mental Health Incidents Update (Elizabeth Jeffs, Tess Ahern, Anne Brebner) The report was taken as read. Ms Jeffs and Ms Ahern provided key points:

• Incidents decreased during Covid, potentially due to a reduction in admissions and a change in practice during this time. The ‘open door’ policy moved to a closed door policy with no visitors and a higher security presence which may have contributed to the calmness of patients.


Ms Abel-Pattinson asked if that experience was similar to other units nationally. Ms Ahern noted that other units had had a similar experience, but not all units operate with an open door policy. One DHB inpatient unit had people who were Covid-19 positive and had to shut down, which the CM Health team worked hard to avoid.

Ms Glenn asked if the drop in incidents was related to not having visitors and if it is the visitors that cause upset to patients. Ms Ahern advised that that could partly be the case, but that visitors are also an important part of treatment and rehabilitation.

4. PROVIDER ARM PERFORMANCE REPORT 4.1 Executive Summary (Mary Burr)

The report was taken as read. Ms Burr provided key points: • The report was written prior to the Covid-19 announcement on 11 August. • Preparation around any resurgence of Covid-19 is well under way with robust contingency

plans in place to meet the Ministry’s expectations. • Mental Health are still supporting the homeless in motels, linking disaffected peoples into

primary care when needed. • The visitor registration and screening process in place will allow quick contract tracing should

that become necessary. • Priority 1 national targets for colonoscopy and gastroscopy were achieved in June. Planned

care delivery confirmed by the Ministry at 101.7% for May with indicative Planned Care result for June at 101%. Radiology had record volumes in June with additional work to reduce the backlog caused during lockdown.

• Bowel screening programme restarted on 8 June. 109 cancers have been diagnosed since the programme commenced in July 2018. Negotiations with the Ministry are ongoing in relation to indicative and future funding levels and programme design to enable equitable participation.

• The ‘Immunisation on Time’ target for 8-month olds result decreased a little in Q4 which may be attributable to Covid-19, but strong goals to support the programme including incentives are in place.

• Overdue appointments are a focus for Ophthalmology with additional clinics on weekends and evening continuing along with sustainable changes to the models of care.

• The retirement of Jeanette Smith, a psychiatric nurse with 52 years of service, was acknowledged.

• Improvement programmes in Women’s Health include Diabetes in Pregnancy and SMO Rostering Project. A review of the primary birthing strategy and involvement in GROW Manukau Health Park and GROW Middlemore Hospital will take place in the second half of 2020.

• Maternity recorded 610 births in June, down 3% on the previous year but an increase on previous months. Ms Brown asked how many mothers are going to private birthing facilities. Ms Burr advised -approx. 100 low risk births last financial year, but does not have any statistics available.

• Recruitment of midwifery and senior doctors continues locally, nationally and internationally. • Gynaecology acute and electives show a 7% increase with Saturday operating and clinic

sessions completed to assist in reducing the Covid-19 backlog. The complexity and acuity continues to grow. Analysis around access to services for women with uro-gynaecological issues continues.


• Kidz First ED attendances are down 53% overall and data is being analysed to identify the cause (includes Covid-19 impact).

• Contingency planning continues in the Laboratory to further ramp up testing volumes. • A successful and unannounced spot visit by the Ombudsman to Tiaho Mai took place in June. • Faster Cancer Treatment achieved 93% against target in June with referral volumes beginning

to return to normal. • Surgical Services ran Saturday and Sunday clinics during June to reduce the backlog caused

during lockdown. Engagement with the Maaori and Pacific teams ensured the community were aware of this and were supported to get to their appointments. As a result, the DNA rate reduced.

• Facilities and Engineering major projects are mostly on target, with one a little behind due to a slight delay in one of the phases.

Ms Glenn asked if the DHB has the ability to contract and get dispensation for midwives due to shortage in New Zealand. Ms Burr advised they are on the essential workers list and are linked in with appropriate immigration people.

4.2 Financial Results FY2019/20 – CMDHB Provider Arm (Avinesh Anand) The report was taken as read. Mr Anand provided key points: • Pre February the DHB had over-delivered on its discharges and case rates. Volumes dropped in

March, April and May 2020 before coming back strongly in June and over-delivering. Because the DHB had over-delivered in the first 7 months of the financial year, the Ministry did not claw back any funding.

• Received money from ACC for White Island, $10.17M. • The full year to June 2020 result was -$10.93M with key contributors being White Island

patients, the unbudgeted cost of Covid-19, Planned Care catch-up, annual leave accruals being higher, opening of ward 17, and additional ophthalmology volumes.

Resolution (Moved: Ms Brown/Seconded: Apulu Autagavaia) That the Hospital Advisory Committee: Note and receive the reports.

Carried

5. CORPORATE REPORTS 5.1 Fast Cancer Treatment Quarterly Update (Catherine Tracy, Dr Jon Mathy)

Ms Tracy and Dr Mathy provided a presentation. Key points: • Dr Mathy has assembled a working group of tumour stream leads and is beginning to put

together information about what a one stop model of care might look like. • The FCT programme aims to improve patient experience, care quality and timely access across

12 tumour streams, measured by the 62-day FCT target. • Working to identify which tumour streams are problematic, variable month on month. • Steadily improving toward 62-day target, sitting around 85/87% of target.


• Ethnicity performance for Asian, Maaori and Pacific Populations are monitored closely and motivates improvement strategies e.g. the lower performance tumour stream of Gynaecology has high volumes and a high representation of Pacific Island women - this is the focus of improvement work in the service.

• Increase in number of patients graded as high suspicion, which requires an increase in resource. One stop model helps managed patients through 62 day pathway.

• Challenges are maintaining FCT as a core priority on a day to day basis, cost and availability of patient travel to treatment, outpatient clinic demand exceeds capacity, timely access to diagnostics, theatre demand exceeds capacity and quality of referral information from primary care to aid clinicians in decision making.

• Actively focusing on the need to meet the FCT target, ensuring patients are micromanaged, predominantly by the Cancer Nurse Coordinator and the Cancer Tracking team, development of data dashboard to better inform tumour streams of hotspots and breaches, escalation of capacity and demand issues regionally for oncology and surgical and cancer control agency requirements and work plan with an equity focus.

• Current and future focus includes increasing traction and escalation, tumour stream presentation through Cancer Steering Group, optimisation of patient journey, patient transport, development of Qlik data dashboard, escalation of capacity/demand issues regionally and equity focus.

Ms Burr noted that in relation to the Gynaecology tumour stream, obesity is the variable that separates the DHB from ADHB and WDHB and is a major factor in the complexity of patients. Women’s Health is working with Primary Care about earlier diagnosis and the development of a navigator role around Maaori and Pacific that can help with early contact with the service.

5.2 Hospital Services Project Portfolio Overview (Sanjoy Nand) The report was taken as read. Mr Nand provided key points: • There are 71 projects embracing Acute Flow, Ambulatory Care Flow, Every Dollar Counts,

Choosing Wisely, and Technology. Of those, 30 are in execution phase, some are progressing, and some have become business as usual.

• In May, delivery against the target of $30M was 67% with the full year report available at the next ARF meeting.

Ms Brown congratulated the team on handling the high volume of projects. Ms Apa noted that the current volume is probably at the top end of what the DHB would like to manage and are a mix of projects at different stages with a large proportion being Healthy Together Technology projects that are in rollout across the divisions. Resolution (Moved: Ms Glenn/Seconded: Apulu Autagavaia) That the Hospital Advisory Committee:

Note and receive the report.

Carried


5.3 Virtual Site Tour: Emergency Department (Melissa Brown) A pre-recorded video presentation was played to the meeting. Key points: • Multiple activities are happening to reduce the length of stay in ED (6-hour turnaround target)

including an operational improvement and performance plan with key actions and deliverables. Length of stay performance has improved from Q1 78% to Q4 93%.

• In Q3, ED has moved from 19th position nationally to 13th with Q4 results due on Friday. Ms Mahuta asked if Mental Health triage takes away from the responsiveness. Ms Brown advised that she doesn’t have specific numbers but there are a number of Mental Health patients who present every day, are often quite complex and may have other issues such as drug and alcohol concerns. There can sometimes be delays in a member of the Mental Health team reviewing the patient, so they need to remain in ED until they are sober and their blood results become available. The ED team is working with the Mental Health team and looking internationally at what is best practice, possibly a Behavioural Observation Unit, and what that would look like. Dr Perese referenced a brief conversation held in CPHAC around Emergency Q for Maaori and Pacific presentations that opt to be referred to urgent care. Dr Perese asked what proportion of Maaori and Pacific who present at ED are opting in to Emergency Q. Ms Brown advised that currently they are seeking better understanding of who uses the vouchers. Primary care are completing data analysis around the types of patients sent, those that re-present and will have an equity cut to allow the DHB to better understand how Maaori and Pacific use the service, if the numbers are higher and what we can do to address. Dr Seddon advised that Ko Awatea has undertaken an evaluation of Emergency Q. One of the issues is that sometimes patients are referred to Emergency Q before they are registered by ED so the ethnicity data or NHIs are not available for every person. Dr Seddon commented that the process of how people get vouchers needs to be reviewed as it would be best if they are all acknowledged in some way. Mr Clark asked if the DHB has thought about receiving the Emergency Q voucher at the other end of the process, rather than giving it to the patient at ED. Dr Seddon advised that the voucher doesn’t cost the DHB anything if it is not used. WDHB are looking at expanding the app so the patient can get the voucher from home, but it looks to be a more expensive option. Ms Abel-Pattinson asked for the name of the company who developed the app. Dr Seddon advised she did not know the name of the company, other than it was a private company, and that the DHB was piggy-backing on WDHB’s experience. The app allows ED to advise patients of the waiting time at each of the urgent care centres. Ms Abel-Pattinson asked what the price would be to make the app the same for WDHB and CMDHB. Dr Seddon advised it would be in the region of several million dollars. Dr Yang asked if it would be appropriate to invite the GM of Primary Care to the next HAC meeting to present.

Ms Abel-Pattinson asked if the DHB were to make the investment, would it pay off in 2-3 years. Mr Nand advised that the number of patients per day that would choose to go to an urgent care centre from ED was quite low, 6-12 per day, increasing to 25-30 on weekends, so it is unlikely to have much of an impact on savings. Ms Abel-Pattinson noted that the Committee would leave it with ELT to discuss and resolve.


5.4 Strategic Deep Dive: Patient Flow - Presentation (Dr Vanessa Thornton) Dr Thornton provided a presentation to the meeting. Key points: • Work commenced two years ago on vision to improve hospital flow (triage to registration to

emergency medicine and transfer to speciality) and care of patients and staff. • Three-pronged approach taken – appropriately redirects specific presentations from ED,

increase ED efficiencies and improve and streamline the admission process. • Daily presentations greater than 15-years+ have returned to normal levels, but children

tracking at about 50% of previous levels over past 10 years. • To reduce presentations, the team have worked with Comms about access to care, provided

Emergency Q which redirects patients back to the community free of charge, is using St John transport to urgent care and GPs rather than ED and encouraging use of the Urgent Care Network through which the DHB subsidises after hours care.

• Emergency Q vouchers issued typically 2-300 per month and up to 500 in busier times. • ED improved efficiencies through senior-led decision-making with a SMO or senior nurse

ensuring patients are streamed through to services where appropriate or redirected to other services, changing the triage process, new A-D (Admission to Discharge) planner and increasing the number of providers, new senior nurse-led model and senior night cover.

5.5 Operational Deep Dive: Emergency Department - Presentation

(Dr Vanessa Thornton, Melissa Brown) Dr Thornton and Ms Brown provided a presentation to the meeting. Key points: • In 2019 116,700 presentations to ED. • Conversion rate at 36% is similar to other emergency departments. However complexity

compared to other DHBs and Australasian health services, particularly for general medicine patients, is higher than the average.

• Achieving 84% admitted patients out of ED over 6 hours with ED discharges at 90% in under 6 hours.

• Covid-19 Level 4 patient flow resulted in 30-40% reduction in workload and results improved during lockdown period.

• Projected growth in ED has been static in past 12 months, by 2026 projecting 128,000 patients through ED. On a daily basis 400 patients, with highs and lows getting higher.

• Improvements achieved in monitored corridor patients and Wait Room B. • Increasing complexity and multi-morbidity of general medicine is similar to Whangarei. • CMDHB has lower admission rates (0.79) compared to North Shore and Auckland. • Senior led triage is first step toward other models of care to address projected growth. • Additional efficiencies in ED include an increase to providers, ED nursing leadership, night SMO

cover and realigning existing workforce to better meet patient needs and surges in demand. • Current data for 6-hour length of stay near 92%. Significant improvement in performance

achieved over last 7-8 months up from the 70%s in Q1. Overall compliance 90.7% in July. • Future improvements – model for behaviourally disturbed patients, monitored and resus

demand, design of facility, helicopter pad and radiology hub. Ms Apa noted that the helicopter pad is at the back of hospital, 1km from the ED. Feasibility of installing pad on top of the Harley Grey Building to shorten the time of transfer has been scoped and is an area of interest raised by the National Trauma Network. This is being added to the capital plan and waiting prioritisation.


6. INFORMATION PAPERS 6.1 Inpatient Experience Snapshot Report

Noted.

6.2 Living in a World of Covid-19 Noted.

6.3 New Zealand’s Place in the World; Implications of Covid-19 Noted.

7. RESOLUTION TO EXCLUDE THE PUBLIC

Resolution (Moved: Ms Brown/Seconded: Ms Glenn)

That the Hospital Advisory Committee in accordance with the provisions of Schedule 3, Clause 32 and Sections 6, 7 and 9 of the NZ Public Health and Disability Act 2000:

The public now be excluded from the meeting for consideration of the following items, for the reasons and grounds set out below:

General subject of items to be considered

Reason for passing this resolution in relation to each item

Ground(s) under Clause 32 for passing this resolution

Public Excluded Minutes of 1 July 2020 and Actions

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

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

Draft Work Plan 2020 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)]

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

Carried


The Public Meeting closed at 3.08 pm.

The next meeting of the Hospital Advisory Committee will be held on Wednesday, 9 September 2020.

Signed as a true and correct record of Counties Manukau District Health Board’s Hospital Advisory Committee meeting held on 12 August 2020.

Catherine Abel-Pattinson Chair

Date

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


Hospital Advisory Committee Meeting – Public Action Items Register – 9 September 2020

DATE ITEM ACTION DUE DATE RESPONSIBILITY COMMENTS/UPDATES COMPLETE

26 February 2020 2.1 Minutes of HAC 20 November 2019 Item 4.5 Equitable Health Outcomes

Post Workshops

Ms Apa

26.02.20 Board workshop dates to be agreed by Ms Apa prior to the next Board meeting with an update provided to HAC after the workshops have been held.

1 July 2020 3.1 Executive Summary Ms Burr to advise the Committee of the learnings from the audit into the May 2020 reduction in volumes and occupancy of Neonates.

Future Date

Ms Burr

12.08.20 A further update is to be provided by Ms Burr when information becomes available.

26 February 2020 4.5.1 Safety, Experience, Compliance and Measurement Dashboard Mr Nand to provide data relating to MedChart sentinel events and schedule a report for a future meeting.

4 November 2020

Mr Nand

02.02.20 Mr Nand has advised the data will not be available until September and therefore will provide a report at the November meeting.

1 July 2020 4.5 Strategic Deep Dive: Future Integrated Cancer Clinic Opportunities Dr Mathy to put together a draft outline that can be built on, based on the areas discussed. Dr Mathy to liaise with Ms Burr and Dr Watson with an update on progress provided at the 9 September meeting.

9 September 2020

Dr Mathy/Dr Watson




12 August 2020 2.2 Disclosed Interests Secretariat to update Disclosed Interests register to reflect change advised by Apulu Autagavaia.

9 September 2020

Secretariat

12 August 2020 2.2.2 Clinical Chiefs Workforce Meeting Ms Jeffs to provide details of the Staff Survey results and action plans being developed. In particular, addressing how the DHB will create a workplace where people feel safe and the method that will be used to monitor this. Details to be included in Human Resources Quarterly report.

9 September 2020

Ms Jeffs

12.08.20 Transferred from Public Excluded Action Items Register

12 August 2020 3.1 Confirmation of Minutes Secretariat to check link provided to virtual tour of MMC and advise outcome.

9 September 2020

Secretariat

12.08.20 The provided link was checked and is working correctly. Whilst the agenda item for this video was noted as being a virtual tour of MMC, it is in fact focussed on the Incident Management Team based at MMC.




Standing Action Items for Each Meeting

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

Under Development

David Hughes

01.07.20 Report content under development. Remove from the agenda until such time as it has been finalised.

31 January 2018 6.11 National Bowel Screening Programme Provide a regular update at each meeting, to be included in Executive Summary.

9 September 2020

Catherine Tracy/

Mary Burr




Quarterly Standing Action Items (Every Alternate Meeting)

9 April 2019 CM Health Board Meeting

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

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

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

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

4 November 2020

Catherine Tracy

31 January 2018 6.1 Hospital Services 2018/19 Project Initiatives Provide a quarterly report on current projects.

4 November 2020

Alan Whiting

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

4 November 2020

Jenny Parr

Moved from September to November meeting at the request of Dr Freeman to

coincide with availability of reports

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

09 September 2020

Elizabeth Jeffs

19 February 2019 Email from M Apa

4.3

Patient Flow – Every Hour Counts Provide a quarterly update including tracking of KPI progress.

09 September 2020

Mary Seddon


Counties Manukau District Health Board Hospital Advisory Committee

Hospital Services Executive Summary – September 2020

Recommendation It is recommended that the Hospital Advisory Committee: Receive the Hospital Services Report covering activity in July 2020. Prepared and submitted by Mary Burr, General Manager, Division of Women’s Health on behalf of the Hospital Services Directorate. Glossary CCC Critical Care Complex EWS Early Warning Score ESPI Elective Service Productivity Indicator FCT Faster Cancer Treatment FSA First Specialist Appointment LOS Length of stay MECA Multi-Employer Collective Agreement MERAS Midwifery Employment Relations Advisory Service (union) MHP Manukau Healthpark MOH Ministry of Health NHI National Health Index NZNO New Zealand Nurse Organisation (union) PSA Public Service Association (union) SMO Senior Medical Officer WIES Weighted Inlier Equivalent Separations (MOH activity based funding methodology) Overview This summary provides a consolidated view of organisational performance in the CM Health Hospital Services Divisions for the month. It is important to note that this report reflects hospital operations during the Covid-19 pandemic Level One. Part A – CM Health Hospital Services Covid-19 Update for July 2020 Current Covid-19 Status For the month of July 2020, the hospital and community remained in Covid-19 Level One. CM Health returned to business as usual levels with a focus on recovery, meeting the needs of patients and the hospital services under the CM Health Winter Plan 2020. Visitors to CM Health Facilities Throughout the Covid-19 alert levels, CM Health has managed and restricted visiting to hospital sites by strengthening our policies and processes. In the current environment it is important that we know who is on our sites, that we screen visitors and that we manage the risk of any infection. Maintaining our registering and screening of all visitors will be an important health and safety activity as we move forward during 2020.


Preparedness for Resurgence During July, the organization focused on working towards preparedness for any future COVID-19 resurgence. Reduce Incident Management Team (IMT) meetings took place three times a week in July. The Divisions all undertook work on renewing plans for any resurgence. Part B - Hospital Services Report - July 2020 Key Highlights for July 2020 • Priority 1 national targets for CM Health colonoscopy and gastroscopy were achieved in July 2020. All

other colonoscopy priority targets have also been met.

• Breast Screen Counties Manukau (BSCM) screened the highest ever total number of women in a month and the highest number of Maaori women in July 2020. A total of 3,160 women were screened including 399 Maaori women.

• Total Planned Care Delivery (Electives) for June was confirmed by the MOH at 104.2% of planned

production. The indicative Planned Care result for July 2020 is at 100%.

• For CT, the percentage of patients seen within 6 weeks has improved from 51% in May to 87% in July. For all modalities combined 86% of imaging was completed within 6 weeks, the best monthly result since June 2017.

Finance Overview – July 2020 The Provider Arm produced a $(1.9) M unfavourable result against budget for the month of July 2020. This contributes to the consolidated DHB variance of $(1.7) M to budget for the month. Delayed implementation of centralised savings programmes, $(1.5) M, CM Health continuing response to COVID19 $(347) k and delivery of additional volumes against contract in July (Acute and elective 3.4%) have driven the unfavourable variance for the month. MSC theatre utilisation was close to 87% compared to 85% same time last year and the theatre minutes were at 72% compared to 68% last year. There were 8,864 ED presentations in July, similar to presentations pre COVID-19. The level of vacancies across the services in hard to recruit areas and delays of approved initiatives have partly mitigated this impact. The E$C (Every Dollar Counts) Savings Work Plan will deliver programmes with more focussed efforts where all projects are targeted, resourced and aligned to strategy. CM Health is transitioning to take responsibility for health care delivery to returning New Zealanders in the 18 Managed Isolation and Quarantine Facilities (MIF) from MoH as at 1 August. Other COVID-19 activity continues within the DHB, including standing up of Community Based Assessment Centres (CBAC), testing and screening for COVID-19 and enabling patient care in the hospital. Key Updates requested by the Hospital Advisory Committee (The Committee has requested regular update on the following items each month). National Bowel Screening Programme (NBSP) Update Since the commencement of the programme, there has been 1,671 positive FITs (faecal immunochemical tests); 1,247 colonoscopies completed, out of which 1,108 patients had biopsies. 110 cancers have been diagnosed since the programme commenced in the DHB in July 2018. As at the end of March 2020 total participation in the programme was 53.4% for Maaori, 52.0%, Pacific 41.6%, Asian 50.6%, other 59.6% (Please note this data is reported in retrospect after collection of all information). We have received our contract variation from the MoH to deliver the programme up to June 2022 and funding has been increased to support additional histopathology costs.


Our nurses completed the backlog of pre-assessments during COVID-19 and all diagnostic tests for this group have now been completed. As of last week, we are starting to see a return to normal levels of FIT+s per week (around 25 FIT+s per week). Our Community Co-ordinators have restarted our Outreach process and we are calling priority participants who have not returned a kit. The MoH have implemented a drop-off option for CM Health and WDHB. This allows participants to drop off their completed kit at any CM Health Labtests location in Counties Manukau. A letter advising of this is included in packs going out now. ADHB is due to go live in November 2020 and Northland in 2021. WDHB has organised a Northern Regional Hui on the 20 August 2020 in Silverdale so that we can to share learnings and reflect on how we can reach equitable health outcomes for Maaori within the Bowel Screening programme. Proportion of 8 month olds who have their primary course of immunisation on time (Target 95%) This target measures the proportion of 8 month olds who have their primary course of immunisation (six weeks, three months and five months immunisation events) on time.

NATIONAL HEALTH TARGETS- Q4 Total Maaori Pacific Comment

Proportion of 8 month olds who have their primary course of immunisation (six weeks, three months and five months immunisation events) on time (Target 95%)

91% 82% 91%

Immunisation coverage over the past three months has decreased by a further 1% for total population and 2% for Maaori.

For Counties, the April coverage was reported to be the same as the month before which may have been reflective of immunisations given prior to lockdown in April. May and June showed a decline in immunisations which may represents the community concern and hesitation to take their babies to a general practice. We continue to work to achieve our improvement goals as follows: • There was an increase in requests from families whose babies were due for a timely immunisation to

request a home visit from the Outreach Immunisation Team (OIS) as they were concerned about going to a GP practice due to the Covid risk. These requests were prioritised for Maaori babies.

• By comparison to Quarter 3 the OIS team saw 60 more babies overall immunising 25 more at home and 17 more at the GP after an OIS follow up with the family than last quarter and 39 of these 60 babies were Maaori babies, despite all the challenges.

• Referrals to Outreach Immunisation services for Maaori and Pacific babies were prioritised throughout the quarter by the National Immunisation Register (NIR) team.

Ophthalmology Overdue Follow up Appointments In July, the Ophthalmology Service has continued to make significant inroads into all areas of service demand including reduction in the number of people waiting longer than 50% of the intended time for a follow up appointment. Saturday clinics continue to be well supported by staff with 9-10 SMO clinics running all day with nursing, allied health, technical and administrative staff. Evening clinics continue to be held on Tuesday and Thursday each week. Celebrating Our People

Te Puawaitanga (Child and Youth Mental Health Services) celebrated Dr Lauren Morris being awarded the Local Hero award. Te Puawaitanga hosted the event with CEO Margie Apa and honoured Lauren and her partner with kapa haka and

presentation. The celebration was a real boost to Lauren and the team.


Tiaho Mai celebrated Pacific Language Week by using the language of each of the Pacific Islands. Staff and service users made decorations and taught each other greetings. On occasions staff and service users gathered together to share food from the relevant Pacific Island. A special mention should go to Ellie Hafoka, Sina Sionetuato, Flo Falemaka and Wyatt for their and their family’s efforts to provide a cultural experience to the unit at the end of Niue Language Week. We celebrated fantastic group work from the ARHOP General Rehab team which included Jo Paton, the Therapy Assistant and recent local hero recipient, who have developed a garden area alongside the Middlemore Foundation outside Ward 23. Divisional Highlights for July 2020 Women’s Health Maternity There were a total of 630 births in CM Health facilities in July 2020; 638 babies (8 sets of twins) were born and the split across facilities was similar to the 2018/2019 year with 10.3% at the DHB Primary Birthing Units. Birth volumes are slightly higher than the average for 2019 - 2020. Gynaecology Gynaecology discharges for the month are at 453 (21% increase on July 2019) and of total discharges, 9% are from outsourced services. High spikes for acute admissions continue each week. Considerable analysis continues around access to services for women with uro-gynaecological issues and we are exploring a number of opportunities in this area. Kidz First For the month of July 2020, ED attendances were at 1,262 (prior year 2,382) – a 47% reduction – mostly due to a decrease in attendances since the COVID-19 lockdown periods commenced as well as not having influenza or other respiratory conditions such as bronchiolitis in the community (likely due to extended lockdown and no international travel). Neonatal Volumes Following the unusually low volumes during April and May (lockdown level 4, 3 and 2) we saw occupancy and acuity in the Neonatal Unit increasing in June and in July increasing further with an average of 109% (midnight count) occupancy, i.e. an average utilisation of 37 cots for the whole month against the 34 resourced cots, with a maximum occupancy of 44. Total Neonatal WIES (i.e. Neonatal Unit and those babies graduating from Neonatal Unit to Postnatal ward and then discharged) is at 103% on the prior 12-month period. Discharges for Neonates from the postnatal area and the Neonatal Unit combined are also up at 104% on the prior 12-month period. Planning for the Neonatal Unit Expansion made excellent progress in July with functional brief and concept design completed. The confirmed space option is to use the adjacent corridor space to the Unit for expansion of the clinical bed spaces as this will give us significant natural light advantages as well as preserve space currently occupied by Laboratory Support Services. Business Case for the Neonatal Unit expansion is progressing well and preliminary costings look to be within the $5 million MoH allocated funding. Central Clinical Services (CCS) Patient Information Services The WinscribeText Project is underway and will replace MedDocs, the current system which is at the end of its life. WinscribeText will be rolled out incrementally beginning with Renal and Haematology in September.


Radiology With the additional hours worked and the current good staffing levels we have been able to significantly reduce the radiology wait lists. For CT, patients seen within 6 weeks have improved from 51% in May to 87% in July. We expect to be at 95% target in 1 month. For all modalities combined 86% of imaging was completed within 6 weeks, the best monthly result since June 2017. Food Services Work has been ongoing to introduce TrendCare to the wards to use for ordering diet meals. Trendcare will replace the current ordering system ‘Task Manager Meal Information’ (TMMI) and is used by the other regional DHBs in the Food Service Agreement. This will make any imposed changes to the menu management system easier and cheaper to achieve.

Laboratory Services The MOH has required all labs to create a contingency to increase Covid testing to approximately double our rate at the previous peak usage. This will entail pooling of samples and running equipment through in to the night (potentially even three shifts). July 2020, as measured in specimen numbers, is very close to July 2019. However, the challenges have been much greater with CM Health striving to increase throughput in electives whilst the lab continues have significant other work related to Covid testing. Mental Health and Addictions Service All PHOs in the Counties Manukau Health district now have their Integrated Primary Mental Health and Addiction Service (IPMHAS) Agreements for the Health Improvement and Health Coach roles and service. Of the 25 practices to implement the IPMHAS Service in the 2020-2021 year, 8 practices now have some elements of the model and 3 practices have all elements i.e. Health Improvement Practitioner, Health Coach, Awhi Ora and Wellness Support. Awhi Ora has a focus on short term ‘walk alongside’ support for people and their whanau who have mild to moderate wellbeing needs, access can be via the community, self or general practice. Integrated Locality Care (ILoC) has a focus on linkages and connection with secondary services, via general practice with clinical input and advice as well as NGO support. The NGO providers and the CNS group will meet monthly to ensure ongoing conversations and review of ILoC and Awhi Ora alignment. Wellness Support has been implemented in all general practices in the Counties Manukau district. July saw over 4000 consultations provided, with an increase in the proportion of people under 25 years accessing support seen. The proportion of Maaori accessing support remains stable at 17%, there has been an increase in the number of Pacific accessing help, although more work needs to occur to ensure Pacific people know funded wellbeing support is available to them via general practice. The Suicide Prevention office has established a Maaori Expert Reference Panel that provides the Suicide Prevention Office expertise, high level strategic advice, support and guidance on matters relating to Maaori suicide prevention and implementation of He Tapu te Oranga. The Maaori Expert Reference Panel has confirmed the key messages for the Office: • Strong, healthy, connected whānau, families and communities are the most important protective

factors against suicide. • People who die by suicide are almost always acutely distressed but are not necessarily mentally ill. • Support and health services are available and do make a difference - they can and do help.

People can be effectively supported through suicidal distress, especially when support is readily accessible.

• Suicide is not a disease, and it is unhelpful to describe our suicide rate as an epidemic. • Collaboration across government agencies will be necessary to prevent suicide. • The reasons that people take their own lives are complex and informed by factors that accumulate over

a lifetime, culminating in suicide when faced with an exacerbating stressful event. • There is no one-size-fits-all in suicide prevention, and different cultural and ethnic groups must be

supported and empowered to design and deliver their own approaches to suicide prevention.


• Suicide risk is associated with inequity and social determinants such as intergenerational poverty, homelessness, poor educational engagement and attainment, unemployment, colonisation, institutional racism and alcohol and other drug addiction.

• Suicide risk is also associated with experiences of trauma: violence, sexual violence, abuse, isolation and marginalisation, unresolved grief, relationship breakdowns, and bullying and harassment.

• Suicide risk also correlates with intergenerational trauma and adverse childhood experiences. • Aotearoa New Zealand’s suicide rate will not come down until inequity, trauma and adverse childhood

experiences are addressed at a societal level. • The focus for suicide prevention should rest with communities, with whānau, with community

leadership and with community services, supported in a sustainable manner by local and central government.

During Level 4 lockdown there was some inaccurate speculation that suicide numbers had increased due to Covid-19. The Chief Coroner’s office made an unprecedented statement (outside of usual reporting) to say that in fact this was untrue and in fact the numbers had been lower than previous years. Clinical Safety and Risk Assessment, Safety Planning and Risk Management with Individual Service Users (Safety Planning). This project has dedicated project support and leadership with the Manager of Clinical Quality and Risk. The Mental Health and Addictions team has embarked on a service-wide transformation that aims to improve health and equity for all populations, provide the best value for public health system resource, and improve the quality, safety, and experience of care for our service users. Key to this transformation is shifting the clinical service from a focus on traditional risk assessment, and management of dramatic forms of risk, to more proactive approach to supporting service user safety. Middlemore Central, Emergency Care and Critical Care Complex (CCC) It is notable that adult presentations to ED and CCC are returning to normal however children less than 15 years old presenting to ED and CCC in July 2020 is considerably less (over 50%) than in July 2019. In MMC 40 Visitor Screeners have now been employed. Visitor Screeners are currently stationed at 4 entry doors in Middlemore Hospital and 1 entry door at Manukau Super Clinic. The Emergency Response Coordinator continues to assist with operational functions based in the Regional Isolation and Quarantine HQ in Auckland City Bledisloe House to ensure smooth transition of patients from the facilities to the hospital and back. There is ongoing work with the MIFs (Managed Isolation Facilities) and RIQs (Regional Isolation Quarantine) to ensure the safe transport of patients to Middlemore Hospital. The Division continues to work towards preparedness for any future COVID-19 resurgence. IMT began meeting three times a week during July and division are renewing contingences plans for any resurgence. There continues to be a strong focus on Security to improve the wellbeing and safety of staff and patients at MMH. A new Head of Security and Resilience along with Security guards continue to be recruited. Critical Care Complex During July CCC continues to work towards business as usual and preparedness for any resurgence of COVID-19. In July 2020 CCC adult admissions (presentations) have plateaued and are slightly lower than in June 2019, and this supports the transition back to business as usual. In contrast, paediatric admissions (as a result of reduced presentations) are tracking over 50% less than in July 2019. PAR (Patient at Risk) referrals have increased this month mainly due to an increase in the number of emergency calls. There were 340 referrals to the PAR service in Jule compared to 301 in June, the majority of which were in response to 777 calls (n153).


Medicine & Integrated Care Quality Project A patient allocation quality project is underway with the aim of improving the number of patients who get admitted to the right ward, first time, and to minimize the portion of unproductive time from bed request to ward admission. A number of change ideas based on learnings to date are in testing or in progress. Faster Cancer Treatment FCT Target achieved at 91%. Presentations were given to SLT, ELT and HAC on current hotspots and areas for improvement and will continue regularly. Gastroenterology We have been able to reduce our percentage of patients removed from the waiting list (ROWL) (due to being unable to contact) by at least 7% from the January 2020 rate of 23%. Our ROWL rate has previously been a challenge for the service, however by reviewing and changing the wording in our “invitation to contact” letters, extending the window for contact by 2 days and sending a second reminder text to patients, we appear to be managing this better. This will improve equity of access for patients. We are tracking this trend to determine the long-term impact of our changes and whether or not further work is required. We are also mindful that some of these gains are likely a result of the impact of COVID-19 and the national lockdown. Planning days have been held for the Sleep Service and Psychological Medicine. These were a great success and have identified opportunities for further service improvement, growth and development. Breast Screen During July, Breast Screen Counties Manukau (BSCM) screened the highest ever total number of women in a month and the highest number of Maaori women. 3,160 total women were screened including 399 Maaori women. The previous records were 3,149 total women screened in May 2018 and 386 Maori women screened in May 2017. Surgery, Anaesthesia and Perioperative Services (SAPS) There are a number of improvement projects in train in the SAPs Division: • Theatre Improvement / Optimising the Surgical Journey Project • Working Group Pacific Health / Fanua Ola & SAPS • Insourcing Initiatives for Covid Recovery for Planned Care • Planned Care Waiting List Improvement Plan • Implementation/ Procurement Service Each of these projects has the potential to make important changes to care delivery in the organisation and are being support by the Ko Awatea team where appropriate. The SAPS services have been focussed on the COVID-19 continued recovery and on the Planned Care Improvement one and three year plans. We have had a large focus on setting the budget for 2020/21 and establishing of the Price Volume Schedule (PVS) and production phasing for the services. Services are looking to maximise CM Health share of the additional funding from the MoH for planned care over the next year and we have put together several proposals for consideration by ELT including supporting new Models of Care, equipment and IT enablers to enhance Planned Care delivery.

The Anaesthetic Department has had considerable success in attracting SMOs to work at CM Health. We are continuing with a strong push for SMO employment so that we can meet the demands of CM Health beyond what we currently deliver. These areas include Gastroenterology, Radiology and Cardiology. Adult Rehabilitation and Health of Older People (ARHOP) Strategic planning is completed on Transient Ischemic Attack (TIA) and Atrial fibrillation (AF) prevention pathway/business case to be developed to increase stroke prevention.


Good progress has been made this month with the Allied Health career framework; operation managers have been involved in service mapping and in reviewing new position descriptions alongside Directors of Allied Health. Methods are being developed to best assess the value of telehealth in allied outpatient clinics and methods to incorporate health equity into patient surveys specifically within hand therapy and scar management. Despite high caseloads, Community Stroke Rehab (CSR) achieved MOH target for second time in three months and are consistently meeting this now the team is fully staffed. Strategic planning completed on 28th July with good initiatives and plans for the year ahead. Community Stroke Rehabilitation team have been in reaching to the ward, have a presence in daily huddle and have been proactively taking over stroke patients into community which has improved patient flow. The Staff Survey results have been shared with all teams, in general they show that staff feel supported, feel that they make a difference and are able to use their skills effectively. Action plans are being developed for all teams. Some of the allied health staff on Ward 24 has joined the ED-Geriatric team enabling a multidisciplinary team approach at the front door. The team are also contacting all patients post discharge home to ensure that they are coping, have picked up their medication and checking that the support and equipment requested is in place. A potential rapid response team will manage any issues that arise, linking this response with the Community Health Teams. National Health Targets Planned Care

Month Result June 2020 Actual

Result July 2020 (indicative)

SS07 Measure 1 Total Planned Care Interventions

Achieved 104.2% Variance from Plan 1281

Achieved 100.0%

SS07 Measure 2 Elective Service Patient Flow Indicators (ESPI) ESPI 2 (FSA) and ESPI 5 (Treatment) wait time targets

FSA: 1307 breaches Treatment: 279 breaches

FSA: 938 breaches Treatment: 235 breaches

SS07 Measure 4 Ophthalmology Follow-up Waiting Times

Overdue: 5092 Overdue 50%: 2566 Overdue 100%: 1594

Overdue: 4579 Overdue 50%: 2107 Overdue 100%: 1279

1. Planned Care Measure 1: Total Planned Care Interventions

Commentary The beneficial impacts of the June 2020 weekend initiatives were evident in the confirmed June 2020 results with caseweight delivery of 413 CWD more than planned and inpatient surgical discharges 2039 delivered versus planned of 1766, an impressive additional 273 discharges. Both have made some recovery from the impact of COVID-19 in April 2020 and are of a sufficient volume to have surpassed the 85% production level required by MoH for revenue calculation purposes.

2. Planned Care Measure 2: Elective Service Patient Flow Indicators

Principle: Timeliness - Patients receive care at the most appropriate time to support improved health. (ESPIs 1, 2, and 5) Commentary ESPI 2: No patients will wait more than 120 days for their First Specialist Assessment (FSA)


CM Health compliance with the 120-day MoH ESPI 2 target for June 2020 continues to show a high but significantly reduced level of breaches. There were significant volumes in General Surgery, Orthopaedics and Ophthalmology. Results are confirmed as remaining in red territory with 1307 breaches, a result of 15.3% against an orange upper limit of 0.39%. The FSA volumes breaching the 120-day requirement has again shown considerable improvement in July 2020 with a drop of almost 400 over the June 2020 position to be 938 for the month. ESPI 5: Patients given a commitment to treatment will be treated within 120 days It is positive to note that with the release of June 2020 results CM Health has dropped further to 279 ESPI 5 breaches, with a notable decrease of 50 in Ophthalmology. However all surgical services have a level of breach. The major contributors to this total are General Surgery with 68, Ophthalmology with 69 and Plastic with 92. July 2020 provisional results are showing some improvement to be 235 breaches – 79 in Plastic, 483 Ophthalmology and 65 in General Surgery.

3. SS07 Measure 4: Ophthalmology Follow-up Waiting Times Principle: Timeliness- Patients receive care at the most appropriate time to support improved health

SS07 – Planned Care Measure 4 Ophthalmology F/U

Month

Total Waiting

Overdue

Overdue 50%+

Overdue 100%+

Principle: Timeliness Patients receive care at the most appropriate time to support improved health

July 14919 4579 2107 1279

Commentary Progress has been made to improve overdue follow up appointments with the number of overdue appointments reduced to 4579 which is the same as pre-COVID 19 levels. The total number of patient consultations in July reached a new high of 4480 consults and builds on the peak achieved in the previous month of June. DNAs continue to track at 9%. The Saturday and evening clinics make a significant difference to the service capacity.

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.

July

Achieved 93%


Commentary July Performance: FCT 91% (29/32 patients) Overall performance 81% (29/36 patients) Of the 3 capacity breaches: • 1 breached by 1 day due to clinic rescheduling to enable distancing in clinic spaces for COVID-19 • 2 breached by more than 70 days due to delays to diagnostic procedures which were impacted by

COVID-19 theatre delays. • There have been less patients breaching for patient choice or clinical consideration this month. This

may be due to patients improved confidence in accessing health care at COVID-19 Alert Level 1. This month has seen FCT updates provided to SLT, ELT and HAC. This has provided a platform to discuss actions required to address shortfalls. Monthly updates will continue to be provided to SLT and ELT to enable further discussion and escalation. Cardiology Angiography

Description May June July

95% elective angiograms within 90 days 85% 85% 100%

Commentary Target achieved Colonoscopy

Description May June July 95% elective angiograms within 90 days 85% 85% 100%

Commentary All colonoscopy targets for the month of July have been met. Gastroscopy

Description May June July

85% urgent (P1) gastroscopies done within 14 days 100% 100% 100%

70% non-urgent (P2) gastroscopies done within 42 days 34% 47% 54%

70% of Surveillance gastroscopies done within 84 days 100% 96% 100%


Commentary All gastroscopy targets for the month of July have been met except for the P2 target. This is still the result of COVID-19 and the national lockdown. We are however improving month-by-month and anticipate 2-3 months until we are able to achieve our P2 gastroscopy target again (provided we have no further limitations on production as a result of regional or national alert level changes in response to the pandemic). Our mitigation plan includes additional weekend gastroscopy lists (for a short period of time due to nursing shortages), utilising un-filled slots on NBSP as available and maximising gastroscopy production via routine weekday lists as able to. We are still waiting on the outcome of the Gastro outsourcing paper 20/21. Diagnostic Access Radiology CT and MRI

Month May June July Maaori Pacific

CT 51% 66% 87% 87% 83%

MRI 41.5% 51.5% 61% 55% 60%

Commentary The demand for MRI is increasing; however we have put three plans in place that are having a positive effect: • We have implemented a vetting process with the Grade MRITs undertaking vetting of straightforward

referrals online and it has reduced the workload for the SMOs who still currently print off and vet referrals manually. The MRITs are vetting approximately 30% of the referrals.

• We changed the MRI template to a ‘specialty’ focused one from a template that required cases to be booked based on who was rostered to MRI for any particular session. We now have sessions for General, ORL, Breast, cardiology etc. and the SMOs are rostered accordingly. This has made a big difference to the booking process, as prior to this change, if for any reason the SMO on the session was unable to attend, a lot of booking changes were taking place.

• Changes have been made to the actual booking template – so that we are ensuring that gaps in the booking times are filled and that batch booking is undertaken wherever possible.

Shorter Stays in the Emergency Department The 6 hour target was met 7 times in July, with a 1.1% reduction in overall performance compared to June 2020. There was a 5% increase in ED presentations for July compared to June (424 more presentations). The chart below shows ED performance over the past 18 months, with significant improvement since quarter 1, trending upwards towards the target, and falling slightly in the winter months, however, much improved on last winter.


ED 6 hour target 95% of patients will be admitted, discharged, or transferred from an emergency department within six hours.

July Not Achieved 91.8%


Hospital Services Directorate – Challenges reported to HAC in September 2020 (July activity). This table provides a snapshot of current challenges.

Division Challenges Reported Update Sept 2020 (July activity) Mitigation Strategies Hospital Directorate

Acute Demand –Beds and TBS

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

In July we were in Level 1 lockdown and ED, CCC & MMC teams returned to business as usual. Adult presentations to ED and CCC are returning to normal however the number of children less than 15 years old presenting to ED and CCC in July 2020 is considerably less (over 50%) than in July 2019.

Outpatient Demand

Jan 18 Increased referral inflow for outpatient care is challenging many services.

Patient Flow- Every Hour Counts Project continues and has some focus on future outpatient modes of delivery.

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

Anaesthetic recruitment continues. We have had considerable success in attracting SMOs to work at CM Health helping us to get closer to our current service size.

Division Challenges Reported Update Sept 2020 (July activity) Mitigation Strategies Kidz First Neonatal Unit

capacity Apl 16 Occupancy in June and in July increased further with an

average of 109% (midnight count) occupancy, i.e. an average utilisation of 37 cots for the whole month against the 34 resourced cots, with a maximum occupancy of 44. Discharges for Neonates from the postnatal area and the Neonatal Unit combined are also up at 104% on the prior 12-month period. Regional Neonatal was capacity at and over capacity for most of July.

Recruitment of nurses and regional cooperation continue. Redeployment of nurses from Kidz First Medical. Additional House Office and Registrar commenced. Weekly updates on capacity and planning for the weekends Transitional care cost i.e. babies from the NICU being reunited on the postnatal floor alongside mothers returning to facility prior to infants being discharged are not at full capacity as yet. The ongoing neonatal unit demand and capacity issues remains on the organisation’s risk register, with monthly reviews in place.

Planned Appointments

May 19 We have been able to continue to allocate more SMO resources to work through the Planned Expired Appointments list resulting in the Planned Expired Appointments decreasing further by 74 to 453 in July (June was 527).

Numbers are reducing through high SMO resource being available.

Division Challenges Reported Update Sept 2020 (July activity) Mitigation Strategies Women’s Health

Caesarean Rate Jan 17 CS rate will be reviewed including the rise in Grade 2 Emergency CS.

We will be re-engaging with MCDHB experts to explore use of Misoprostol as part of the IOL project.

Midwifery workforce

Jan 17 Total Midwifery vacancy forecasted for August = 48 FTE (Backfilled by casual/bureau registered nurse or midwives, health support workers and staff working additional shifts or overtime). Other health workforce groups e.g. Health Care Assistants and Registered Nurses do not have recruitment challenges.

We continue to cast a wide net to recruit including overseas recruitment with early success.


Division Challenges Reported Update Sept 2020 (July activity) Mitigation Strategies Women’s Health

MCIS Apl 17 Scoping CTG integration prior to Global go live. Regional project is reviewing Clinical Portal requirements for data from MCIS. Transition to Client Version 3.0 required in December 2020; also required for transition to Global. Windows 10 is required prior to Global transition in April 2021.

Timeline for go live with Badgernet Global extended to April 2021 (Covid UK related delay).

Gynaecology Apl 17 Due to the on-going reduced theatre capacity issues we have needed to decrease FSA volumes with more women now being placed on the GP residual list (P3 patients).

On-going work in close partnership with SAPs on the production plan for electives continues as well as maximising the opportunities for Acute Arranged volumes on the MMH site and outsourcing.

July 20 The need for a strong perinatal loss service has been exacerbated by a change in legislation.

The Division has highlighted the need to extend the current service and requested an increase in staffing numbers and expertise within a number of funding requests.

Division Challenges Reported Update Sept 2020 (July activity) Mitigation Strategies Medicine and Integrated Care

Bowel Screening Programme

Jul 17 Since the commencement of the programme, there has been 1,671 positive FIT tests; 1,247 colonoscopies completed, out of which 1,108 patients had biopsies. 110 cancers have been diagnosed since the programme commended in the DHB in July 2018.

Going into GP Practices and working with PHOs to undertake Query Builds to promote to priority populations who have not returned their kits yet. We have raised the issue that 30% of CM Health participants on the NBSP register are missing GP/Practice information, resulting in negative results not going out to GPs.

Increased no of patients requiring In-Centre Dialysis

The Renal Service is under pressure.

The completion of phase 1 and 2 in both MSC and Rito has given an additional 9.1 FTE (3.3 FTE is for Rito for 12 patients and 5.8FTE is for 39 additional patients for MSC in-centre. Phase 3 - The final phase of the approved business case for more staff (to increase capacity), will enable more shifts, and an additional 7.4 FTE for Rito, enabling an additional 23 patients to be dialyzed.

Local Delivery Medical Oncology

May 19 The regional Cancer Services Group (NRICS) has approved in principle the next stage for local delivery of medical oncology. This is now going through a series of groups regionally and locally for further discussion and approval.

Some outpatient appointments continue to be telehealth, mainly telephone and this may continue to be the preferred appointment method for some patients going forward. The clinic rooms in Galbraith Infusion Centre have been set up with multimedia monitors to facilitate this. ELT has approved the extension local delivery to provide a comprehensive medical oncology service to patients with breast cancer, where by patients will only attend ADHB when they receive radiotherapy treatment.

Faster Cancer Time Target

Gastroenterology currently relies on the cancer nurse coordinator for upper GI (Surgical Services FTE) to deliver support and coordination for patients in the liver tumour stream on the FCT pathway. This is no longer tenable.

A business case has been drafted addressing this requirement. In the interim Cancer Services have offered to “loan” 0.5FTE of cancer nurse coordinator FTE to this role (with a nurse already available) however this will be for 6 months only.


Division Challenges Reported Update Sept 2020 (July activity) Mitigation Strategies Medicine and Integrated Care

Medical Staffing Nov 2019 Recent loss of the Respiratory Research fellow (rotating position within Medicine) has left the Respiratory Service down in terms of clinical capacity. This will increase our reliance on custom clinics to be able to meet demand. We are also seeing an impact on weekend RMO ward cover as a result as this role was utilised to provide some weekend ward cover.

We are drafting a business case requesting a Respiratory Research fellow embedded with the service (and partially funded through the Respiratory Research fund)

Bronchoscopy There is urgent and escalating need for more access to GA lists for Bronchoscopy. The current waiting list is at 40 (increased from 25 in May) patients (and this is leading to delays to diagnosis and treatment, increasing clinical risk for acutely unwell patients and impacting on those patients on the FCT pathway. COVID-19 has also caused delays to procedure.

The bronchoscopy waitlist is fluctuating; however the service has been offered several ad hoc GA lists to support bronchoscopy production, which is helping us to manage this list currently. The service continues to provide Saturday bronchoscopy lists at least twice (up to 4 times) per month. This remains challenging due to the shortage of endoscopy-trained nurses and ongoing issues with inability to cover increasing sick leave in this workforce.

Division Challenges Reported Update Sept 2020 (July activity) Mitigation Strategies Central Clinical Services

MRI staffing Jun 20 MRI MRT staffing Current advert out for MRI trained MRTs, no applicants in 6 weeks. Exploring options with external contractor as previously arranged.

Radiology- RIS-PACS

Aug 20 The Radiology Information System – Picture Archiving and Communication System (RIS-PACS) where the images recorded are not all transferring to the PACS in an appropriate manner. Some of the images are loading slowly, and some are loading in a relatively long time after the fact. This gives the radiologist doing the reporting, particularly for acute care, the impression that all the images have loaded and an initial report is commenced. When the balance of images arrives in the PACS they can be missed by the reporting radiologist.

This has been entered onto the Risk Register and there are investigations underway to ascertain the cause of this. We are not aware of ADHB or WDHB (with whom we share the RIS-PACS) having similar issues.

Food Service -Meals on Wheels

Aug 20 New model of provision of the Meals-on-Wheels service has created issues which are slow to be acted on by the contractor. The issues involve both the nutrition content and quality of meals being distributed.

We continue to work actively with the supplier to resolve this issue. This was a change that was made nationally and impacted multiple DHBs.


Division Challenges Reported Update Sept 2020 (July activity) Mitigation Strategies Mental Health and Addictions

Workforce Recruitment

Across the CM Health MH&A division there continues to be areas with significant workforce recruitment and retention issues. Intake and assessment is another team that is experiencing high vacancies and is working to ensure an acute response is able to be provided across CM Health.

Overall vacancy rate sits at 16.3% (19% Dec) however there are 5 psychology interns employed on top of this who provide some support. Contributing to the improvement in the overall rate is the over recruitment in OT (18%) and SW (13%) as interim approach. Contingency planning in place and new pilot with HML started to provide support for triage of referrals within working hours as well as after hours. An additional 6 clinicians have accepted permanent roles with the team and are expected to join over the coming months. The team also continues to rely upon short-medium term SMO locums, however with the expected arrival of a permanent SMO in September and the potential to recruit a further 1-2 long term/ permanent candidates in late 2020, there is a more optimistic feeling within the team.

Rapua Te Ao Waiora (Adult Mental Health team – Manurewa, Takanini Papakura catchment areas

Aug 2020 Rapua Te Ao Waiora is currently struggling to meet the service demands due to a continued increase in clinical requirements and decreased clinical capacity. At present the vacancy rate is 25% (29/ 39FTE employed).

A number of strategies have been identified in order to support the team and to ensure that clinical risk and response are prioritised. Some of these short-medium term actions are as follows: • Development of a comprehensive action plan. Initial stages of this

have been completed, with next step being to meet with the wider staff group, including involvement with PSA, to engage staff in the solution focused approach and prioritisation of activities.

• A focus on recruitment and retention activities (high areas of vacancies for SMO, OT and RN)

• Identifying additional clinical resource from other community teams to support various functions within the team (eg caseload reviews/ discharges, coaching/ mentoring etc.)

Division Challenges Reported Update Sept 2020 (July activity) Mitigation Strategies Surgery, Anaesthesia Perioperative Services

Demand for Ophthalmology Services

Jul16 In July, the Service has continued to make significant inroads into all areas of service demand; Reduction in the number of people waiting longer than 120 days for a surgical procedure Reduction in the number of people overdue for an FSA Reduction in the number of people waiting longer than 50% of the intended time for a follow up appointment.

Progress has been made to get on top of overdue follow up appointments with the number of overdue appointments reduced to 4577 which is the same as pre-COVID 19 levels. The total number of patient consultations in July reached a new high of 4480 consults and builds on the peak achieved in the previous month of June. DNAs continue to track at 9%. The Saturday and evening clinics make a significant difference to the service capacity.

Planned Care Delivery- Impact of COVID-19

Aug 2020 The delivery of our Planned Care volumes have been impacted by COVID-19 lockdowns and the focus for planned care services has been on recovery and on the Planned Care Improvement one and three year plans.

Services are putting in considerable effort to maximise CM Health share of the additional funding from the MoH for planned care over the next year, they have put together several proposals for consideration by ELT for to be submitted that will look at supporting new MoC, equipment and IT enablers to enhance Planned Care delivery.

Counties Manukau District Health Board – Hospital Advisory Committee 9 September 2020 *Due to rounding, numbers presented throughout this document may not add up precisely to the totals provided

Financial Results – CMDHB Provider Arm

Monthly Report – July 2020*

Glossary CMH Counties Manukau Health CBAC Community Based Assessment Centres DHB District Health Board ED Emergency Department E$C Every Dollar Counts MIF Managed Isolation Facility MSC Manukau Superclinic Finance Overview The Provider Arm produced a $(1.9)M unfavourable result against budget for the month of July 2020. This contributes to the consolidated DHB variance of $(1.7)M to budget for the month. Delayed implementation of centralised savings programmes, $(1.5)M, CMH continuing response to COVID19, $(347)k and delivery of additional elective volumes against contract in July (Acute -1%, elective 7%) have driven the unfavourable variance for the month. MSC theatre utilisation was close to 87% compared to 85% same time last year and the theatre minutes were at 72% compared to 68% last year. There were 8,894 ED visits in July, similar to volumes pre COVID-19. A level of vacancies across the services in hard to recruit to areas and delays of approved initiatives have partly mitigated this impact. The E$C (Every Dollar Counts) Savings Workplan will deliver programmes with more focussed efforts where all projects are targeted, resourced and aligned to strategy. CMH is transitioning to take responsibility for health care delivery to returning New Zealanders in the 18 Managed Isolation and Quarantine Facilities (MIF) from MoH as at 1 August. Other COVID-19 activity continues within the DHB, including standing up of Community Based Assessment Centres (CBAC), testing and screening for COVID-19 and enabling patient care in the hospital.

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

RevenueGovernment Revenue 82,829 81,713 1,116 F 82,829 81,713 1,116 F 980,324 979,208 1,116 FPatient/Consumer Sourced 937 1,067 (130) U 937 1,067 (130) U 12,672 12,802 (130) UOther Income 2,414 2,607 (193) U 2,414 2,607 (193) U 30,979 31,172 (193) UTotal Revenue 86,180 85,387 793 F 86,180 85,387 793 F 1,023,975 1,023,182 793 FExpenditurePersonnel 63,845 62,614 (1,230) U 63,845 62,614 (1,230) U 751,615 750,385 (1,230) UOutsourced Personnel 2,048 745 (1,303) U 2,048 745 (1,303) U 10,067 8,765 (1,303) UOutsourced Clinical 2,680 2,907 227 F 2,680 2,907 227 F 34,189 34,416 227 FOutsourced Other 3,905 4,244 338 F 3,905 4,244 338 F 50,584 50,922 338 FClinical Supplies (excluding Depreciation) 11,774 11,408 (365) U 11,774 11,408 (365) U 133,981 133,616 (365) UOther Expenses 7,442 6,975 (467) U 7,442 6,975 (467) U 83,541 83,074 (467) UTotal Operating Expenditure 91,694 88,894 (2,800) U 91,694 88,894 (2,800) U 1,063,977 1,061,178 (2,800) U

Total Operating Surplus/(Deficit) (5,514) (3,508) (2,006) U (5,514) (3,508) (2,006) U (40,002) (37,995) (2,006) U

Depreciation 3,295 3,405 110 F 3,295 3,405 110 F 40,751 40,861 110 FInterest 6 6 0 F 6 6 0 F 72 72 0 FCapital Charge 2,709 2,709 0 F 2,709 2,709 0 F 32,512 32,512 0 FTotal Finance Costs 6,010 6,120 110 F 6,010 6,120 110 F 73,335 73,445 110 F

Net Surplus/(Deficit) (11,524) (9,628) (1,896) U (11,524) (9,628) (1,896) U (113,337) (111,441) (1,896) U

Full Year ForecastStatement of Financial Performance

CMDHB Provider

Month Full Year

Counties Manukau District Health Board – Hospital Advisory Committee 9 September 2020 *Due to rounding, numbers presented throughout this document may not add up precisely to the totals provided


Medical Personnel 20,845 19,695 (1,149) U 20,845 19,695 (1,149) U 240,105 238,956 (1,149) U

Nursing Personnel 24,037 23,848 (190) U 24,037 23,848 (190) U 288,743 288,554 (190) U

Allied Health Personnel 8,407 8,600 193 F 8,407 8,600 193 F 101,983 102,176 193 F

Support Personnel 3,329 3,272 (58) U 3,329 3,272 (58) U 39,516 39,458 (58) U

Management/Administration Personnel 7,227 7,200 (27) U 7,227 7,200 (27) U 81,268 81,241 (27) UTotal (before Outsourced Personnel) 63,845 62,614 (1,230) U 63,845 62,614 (1,230) U 751,615 750,385 (1,230) U

Outsourced Medical 969 473 (496) U 969 473 (496) U 6,026 5,530 (496) U

Outsourced Nursing 271 42 (229) U 271 42 (229) U 714 485 (229) U

Outsourced All ied Health 75 21 (54) U 75 21 (54) U 286 232 (54) U

Outsourced Support 222 - (222) U 222 - (222) U 222 - (222) U

Outsourced Management/Admin 512 210 (302) U 512 210 (302) U 2,819 2,518 (302) UTotal Outsourced Personnel 2,048 745 (1,303) U 2,048 745 (1,303) U 10,067 8,765 (1,303) U

Total Personnel 65,893 63,360 (2,533) U 65,893 63,360 (2,533) U 761,683 759,150 (2,533) U


ARHOP (3,862) (4,092) 230 F (3,862) (4,092) 230 F (48,935) (49,164) 230 F

Central Clinical Services (8,469) (8,609) 140 F (8,469) (8,609) 140 F (101,585) (101,725) 140 F

Child Health Kidz First (3,351) (3,290) (62) U (3,351) (3,290) (62) U (40,007) (39,945) (62) U

Child Youth & Maternity (517) (476) (41) U (517) (476) (41) U (6,003) (5,962) (41) U

ED, MMC & CCC (9,478) (9,889) 411 F (9,478) (9,889) 411 F (119,025) (119,437) 411 F

Emergency Response (347) 0 (347) U (347) 0 (347) U (347) 0 (347) U

Facil ities Services (2,233) (2,294) 61 F (2,233) (2,294) 61 F (27,600) (27,661) 61 F

Innov Hub & Ko Awatea (673) (882) 208 F (673) (882) 208 F (9,340) (9,549) 208 F

Localities (2,624) (2,768) 144 F (2,624) (2,768) 144 F (33,155) (33,300) 144 F

Manukau Health Park (377) (366) (11) U (377) (366) (11) U (4,042) (4,031) (11) U

Medicine (12,440) (12,450) 10 F (12,440) (12,450) 10 F (148,491) (148,501) 10 F

Mental Health (6,887) (6,648) (239) U (6,887) (6,648) (239) U (81,482) (81,243) (239) U

Primary Care (208) (234) 25 F (208) (234) 25 F (2,833) (2,858) 25 F

Provider Management 61,799 63,108 (1,309) U 61,799 63,108 (1,309) U 759,153 760,462 (1,309) U

Surgical & Ambulatory (17,219) (16,345) (874) U (17,219) (16,345) (874) U (195,628) (194,755) (874) U

Women's Health (4,638) (4,394) (245) U (4,638) (4,394) (245) U (54,017) (53,773) (245) U

Net Surplus/(Deficit) (11,524) (9,628) (1,896) U (11,524) (9,628) (1,896) U (113,337) (111,441) (1,896) U

Surplus / (Deficit) by DivisionMonth

Personnel Costs By Professional Group Month Full Year Full Year Forecast

Full Year Full Year Forecast



Provider Volumes Report Recommendation It is recommended that the Executive Leadership Team: Note that provider volumes were previously reported to the Hospital Advisory Committee as part of the Corporate Finance report Note the request to separate out provider volumes into a Provider Volumes report to the Hospital Advisory Committee, and to ask that this report be endorsed by the Executive Leadership Team Note that the format of the Provider Volumes report has been retained for the meeting of the 9 September 2020, however the intention is that this will be revised to include commentary on volumes going forward Endorse the Hospital Funding report to be submitted to the Hospital Advisory Committee Prepared and submitted by: Kate Yang on behalf of Aroha Haggie, Director of Funding and Health Equity Purpose The Executive Leadership Team is asked to endorse the Hospital Funding report to be submitted to the Hospital Advisory Committee for the meeting on 9 September 2020 Appendix 1. Provider volumes for the month of July 2020


Provider Volumes for the Month of July 2020

Glossary ACC Accident Compensation Corporation BOY Balance of Year ED Emergency Department FSA First Specialist Assessment FTE Full Time Equivalent FU Follow Up Appointment FY Financial Year HWFNZ Health Workforce New Zealand (previously CTA (Clinical Training Agency)) MECA Multi-Employer Collective Agreement MoH Ministry of Health WIES Weighted Inlier Equivalent Separation (activity based measurement) YTD Year to Date



Patient Flow ‘Every Hour Counts’ Portfolio Quarterly Progress Report

Recommendation It is recommended that the Hospital Advisory Committee: Receive the Patient Flow ‘Every Hour Counts’ Portfolio Quarterly Progress Report. Note the high level work and priority areas for the ‘Every Hour Counts’ programmes. Note this report was endorsed by the Executive Leadership Team on 25 August to go forward to the Hospital Advisory Committee.

Prepared and submitted by: Lynne Armstrong, Change Manager Ko Awatea on behalf of Dr Mary Seddon, Director Ko Awatea and Senior Responsible Officer Patient Flow – Every Hour Counts Portfolio. Glossary CSSD Central Sterile Supplies Department ED Emergency Department FSA First Specialist Appointment FU Follow Up Appointment MAU Medical Assessment Unit MRI Magnetic Resonance Imaging MRT Magnetic Resonance Technician NASC Needs Assessment & Service Coordination PPPR Protection of Personal and Property Rights Qlik Qlik Sense is a data analytics platform (dashboard) implemented at CM Health PDSA Plan, Do, Study, Act – A methodology used in quality improvement activity RMO Registered Medical Officer SMO Senior Medical Officer Purpose The purpose of this paper is to provide the Hospital Advisory Committee with an update of progress, issues and risks associated with the Acute and Ambulatory Flow programmes of work within the Every Hour Counts portfolio. Executive Summary Patient flow work has continued despite the impact of Covid-19. The acute work has been predominantly focused on flow in the ED and ensuring that patients are admitted to the right bed, first time. Senior-led triage at the front door is showing encouraging results and has recently been expanded to a seven-day service. The introduction of ward co-ordinators onto the medical wards is also improving the timeliness of the discharge process, which is a necessary part of the acute flow process. The ambulatory flow work has been focused on the Ophthalmology clinic, streamlining processes and releasing SMO time. The use of telehealth, which had been stood up quickly during Covid-19 Alert Level 4 and was well used, decreased significantly as lockdown restrictions eased. It is being re-launched as a clinical change process (IT enabled) and the team are working with two ‘willing’ services to identify barriers and ensure that the technology does not produce an equity gap for patients. A major theatre utilisation improvement programme has been launched with good engagement from the Surgery department, and clinicians involved.


Acute Flow Programme The trial of an SMO-led triage of patients presenting in ED has been rolled out and is now occurring on a daily basis (11am-10pm) Monday to Friday, subject to availability of resource. During July tests were undertaken to understand the feasibility of providing this process on the weekends as well as weekdays. Providing a senior decision maker at the front of ED has helped to reduce the impact of surges. It also allows for patients to be transferred directly to specialties, moved to the most appropriate place based on clinical need, and to have diagnostics and treatment started earlier in the care journey. A step change in the number of patients in Monitored Corridor1 and Waiting Room B2 (see Charts 1 and 2) has been observed. This is significant from a patient safety perspective as it means that patients are being cared for in the most appropriate place for their needs. Chart 1: Total Monitored Corridor Patients per week

Chart 2: Total Waiting Room B Patients per week

1 The Monitored area of ED is used for high acuity patients (mainly those presenting with chest pain) who are deemed to require monitoring. The Monitored Corridor spaces are areas for beds to be situated against the Nurses Station, when all ten Monitored spaces are in use. As these spaces are in the corridor (rather than a formal bed space) they do not have monitoring equipment; instead they are visually rounded by nurses, rather than being centrally monitored. Due to their location, they lack privacy as they cannot be curtained off. 2 Waiting Room B is the overflow location for patients who would ordinarily be sent to the Adult Assessment area. The patients sent to this location remain in the normal waiting room, sitting rather than being sent to a bed space in Assessment. These patients are overseen by the same nursing workforce looking after the Waiting Room.

SMO led triage tested on Mondays

SMO led triage all days where

resource allows

Alert Level 4

SMO led triage tested on Mondays

SMO led triage all days where

resource allows

Alert Level 4


There has also been a marked improvement in the six-hour target, and whilst it is not achieved consistently throughout the quarter, improvements continue to be seen – see Chart 3. Chart 3: % Eligible presentations achieving the six-hour target

Middlemore Central Patient Flow Escalation Framework – the Bed Capacity Escalation Level Trigger Tool is now live in a Qlik dashboard, and is reporting five indicators: ED patient volumes, MAU patients, ED bed requests, Isolation bed requests, and Medicine and Surgery physical occupancy percentage. The two remaining indicators: staffing and theatre minutes, are in progress, and are being monitored by Middlemore Central. Patient Allocation The instigation of daily (Mon-Fri) MAU huddles is enabling more patients to be allocated to a home (right) ward – see Chart 4. Once a permanent appointment has been made, an MAU Change Nurse Manager will join the Ward Coordinators, Duty Manager and MAU nursing representative at these huddles to further enhance the team. Chart 4 – Number of General Medicine patients admitted to the right ward, first time Mon-Fri only

95% target


Access to isolation beds remains a significant challenge. A guide to rationalise the use of isolation beds has been developed for Bed Managers by the Infection Prevention & Control team, and has been underpinned by the delivery of two education sessions. Proactive Discharge Planning The introduction of Ward Coordinators (without a caseload) onto five General Medicine wards is working well, and is demonstrating improvements with increased numbers of patients being transferred to the discharge lounge, and those being discharged before 2pm – see Chart 5. This is positively contributing to flow, and is preventing overcrowding in the ED. Chart 5: % Patients discharged before 2pm

Work has commenced to develop and shape a Health of Older People team; a virtual team of subject matter experts who will offer support and guidance to NASC Assessors when they experience blocks in the patient discharge process. Initial testing of the impact of this new team (the ‘HOP Squad’) will take place on Ward 33N. Ward Enablers of Flow During a four week period, data was collected and showed that 28% of total bed-days were ‘red’3, often due to capacity in other services, eg. Echo, Gastro, Specialist review – see Chart 6. However, outliers also remain a challenge to ward huddles; during the fourth week of June 2020, 64% of patients were outliers. Chart 6: Reasons for Red Days

3 A ‘red’ day is a day of no value for the patient 4 The Protection of Personal and Property Rights (PPPR) Act is a legal application made when a person is deemed to not have

the capacity to make decisions about their own personal care and welfare.

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Rapid and Consistent Access to Radiology – MRI • Waiting lists for MRI increased post Covid-19 lockdown due to increased elective related scans and a

shortage of administrative staff. Once administrative issues were resolved, capacity was optimised – see Chart 7 below. o Segmentation of the waiting list continues, with a particular focus on sedation cases (oldest).

Options are being explored to utilise additional nursing and RMO support to help clear the backlog. o Analysis of the MRT vetting trial is underway. Anecdotal evidence from both MRTs and SMOs

report a 30% reduction in SMO workload from manual vetting. MRTs have now widened the range of scans being vetted.

o Between 22 June – 3 August 2020, 246 scans were outsourced.

Chart 7 – MRI Waitlist in Hours - May to July 2020

Compliance with Ministry of Health P2 targets continues to improve as scans are undertaken in a more timely manner – see Chart 8.

Chart 8: MRI Waitlist (# of patients) and Ministry of Health Target Over Time


Issues and risks • There is currently only one full time MRT vacancy in the department, however a further two MRTs will

leave the organisation in November. Roster reforms will help to address this issue until these positions have been filled.

• The use of outsourcing to reduce the waiting list has decreased back to 15 scans per week; this only provides for outsourcing certain cases due to private contractual obligations (often not the ones at the tail-end of the waiting list). There is therefore a risk that the waiting list will increase again.

Ambulatory Flow Programme Telehealth Telehealth, as a mode of delivery for outpatient appointments, has dropped from 65% during Covid-19 Alert Level 4 to 5% in July 2020. Access to data via Qlik has improved visibility of telehealth usage by service. A PDSA for the use of telehealth is underway with Surgery and Cardiology, and is being driven by the service, enabled by Healthy Together Technology. The Ambulatory Flow portfolio team is working with clinical leads in these services to study the process of converting face-to-face follow up (FU) appointments to telehealth; shadowing the process end to end: from patient selection to patient appointment. The purpose of this study is to determine how long the process takes, who should undertake the preparation work, any barriers, the proportion of patients who need to be seen again, or can be discharged. Once this work is completed, the lessons learned will be used to influence the other services to increase telehealth follow up appointments. Ophthalmology • Simplifying the Cataract Surgery Process

The move from face-to-face to telephone FU appointments on the first day post surgery is now business as usual for the service. For uncomplicated cataract surgery, patient FU appointments are now being done by Optometrists, by telephone. In the last three months, this has released 383 (70%) SMO in-clinic FU appointments (approx 127 hours). The remaining 168 patients (30%) required face-to-face FUs. Monitoring of this new process will continue. Combining FSA and pre-admit appointments has been trialled. Patient experience interviews have been completed and whilst patient experience has been positive, there are opportunities to refine the process further. Staff interviews are currently underway.

• Avastin Clinic Process

Currently if during a FU appointment it is deemed necessary for a patient to have urgent treatment, ie. injection, the patient has to wait approximately two weeks for an appointment. A PDSA to treat the patient on the same day has been completed; nine patients participated in this trial. Data is currently being analysed, and staff experience is being captured.

• Glaucoma PDSA

Currently, the service receives ‘soft’ evidence referrals from Optometrists, where initial tests results for Glaucoma are questionable. This results in a number of patients being retested in clinic where previously reported abnormalities are no longer present. The process of retesting is time consuming for patients and clinicians (45 mins for testing, waiting to see an SMO, patient is then dilated and waits a further 20 mins before seeing the SMO again). A PDSA of a technician-led Glaucoma FSA screening clinic with an SMO virtual review was recently completed. Five patients were booked, one did not attend. This trial sees the patient attend the clinic and complete the usual five tests (45 minutes) and goes home. The SMO later reviewed the notes, which averaged 36 minutes in total.


Of the four patients who attended the trial only one patient needs to be in the Glaucoma clinic. This patient will not need a full FSA appointment as most testing has now been done. Three FSA appointments were released for the SMO who can use this time to see higher acuity patients. Analysis of testing times and a review of patient and clinician experience is being completed before a second PDSA is undertaken.

Blood Pressure Remote Monitoring Trial Fifty one Cardiology patients (initial target 25) are currently participating in a blood pressure remote monitoring trial. The results from this trial have been significant, particularly regarding up-titration rates; against a target of 80% (national average is 35%), 92% of patients have been safely up-titrated (72% fully up-titrated), meaning there are no outstanding clinical risks or issue that need to be addressed and no need for a FU clinic appointment.

Ethnicity Device Provider

13 Maaori 12 have been up-titrated, 1 deceased 16 NZ Europeans 13 up-titrated 16 Pasifika 14 up-titrated, 1 in progress, 1 deceased 5 other 4 up-titrated, 1 in progress

Heart Foundation 7 Own 37 CM Health 6 Source unknown 1

Up-titration of Enrolled Patients Up-titration Quality of Up-titrated Patients

46 patients (92%) have been up-titrated 2 patients (4%) have deceased 2 patients (4%) are still in progress

33 patients (72.34%) fully up-titrated 13 patients (27.66%) up-titrated below target Ethnicity analysis on up-titration quality to be completed

Below Target Titration Cause

6 patients non adherence to treatment 3 patients with co-morbidities; two of whom have passed away 4 patients had abnormal lab results

Charts and data analysis are being finalised in order to produce the final report. It is intended that this report be produced for peer-reviewed publication. Optimising the Surgery Journey On any one day, there are over 4,000 patients on the elective surgery waiting list at CM Health, and whilst theatre utilisation often exceeds 90% for both acute and elective procedures, there are inefficiencies in the current system, with patients attending frequent clinic appointments, and high cancellation rates (almost 1,200 ‘day of surgery’ cancellations were made in 2019). Two workshops have been conducted with key stakeholders, where 38 opportunities to improve patient experience were identified. These opportunities have been grouped into five work streams, which have been scoped, evaluated and prioritised:

1. Patient Experience: Improve the experience the patient has throughout the journey 2. Journey Simplification: Provide clarity and streamline the surgical patient journey 3. Information Management: Improve information, allowing stakeholders more visibility planning and

better communication 4. CSSD: Increase compliancy rate and reduce defects rate 5. Operating Theatre Improvement and Capability Increase: Maximise the utilisation of Operating

Theatres. Ensure the right amount of resources Improvement and project team resource for each work stream has been allocated and ‘kick-off’ workshops are planned to determine roles and responsibilities for each project. Each project team will then implement a pipeline of ideas, with an objective to deliver improvements within three months (by November/December 2020).


To ensure patient experience is a key driver for this programme of work, telephone interviews are being planned with patients who have undergone surgery at CM Health in the last three months, as well as those whose surgery did not go ahead. Staff will also be interviewed in order for the projects teams to better understand concerns and frustrations, and opportunities for improvement. As the programme progresses, interviews will be repeated to ensure all changes made have improved patient and staff experience.


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Human Resources Report Recommendation It is recommended that the Hospital Advisory Committee: Receive the Human Resources report for month ending 30 June 2020.

Prepared and submitted by Nirmal Sinha, HR Performance & Systems Development Manager on behalf of Elizabeth Jeffs, Director of HR. Executive Summary HR metrics are provided to outline performance for Annual Leave Balances, Sick Leave, Turnover rates, Recruitment Average Time to Hire and Annual Leave Cashups. Below are the 12-month trend graphs to June 2020. Background The data in this report is to 30 June 2020. Key Features Accumulated annual leave continues to increase. The August report will show the impact of the July School holidays.


Hospital Directorate Health Priority Indicators

Annual Leave Balance >2Years Equivalent in Percentage

• The Percentage of Staff with more than 2 Years’ Annual Leave balance increased 1.78 % (↑) in June 2020 compared to June 2019.

Annual Leave Balance > 2 Years Equivalent by Occupation Group

• The Percentage of Staff with more than 2 Years’ Annual Leave balance is highest in Nursing, followed

by Corporate and Senior Medical.

9%10%11%12%13%14%15%16%17%18%19%

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

> 2 Years > 2 Years LY UCL Average LCL

3.44%

8.69%

15.92%

0.95%

5.25%

47.16%

11.79%

6.80%

0%

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Allied Health Care andSupport

Corporate andOther

ResidentMedical

Midwifery Nursing Senior Medical Technical andScientific

Percentage of CMDHB Workforce with Annual Leave Balances> 2 Years' Equivalent (Occupation Group)


Total Annual Leave Paid Hours in Percentage

• As expected, Annual Leave Paid is trending down, for June 2020 is at 4.68%. • In comparison to June 2019, Annual Leave utilisation for June 2020 is 34% lower.

Sick Leave as Percentage of Total Paid Hours

• Sick leave is trending up since Apr 2020 and June 2020 is at 3.5. • In comparison to the June 2019, sick leave utilisation for June 2020 decreased by 0.29% (↓). • A target of 3% has been set for sick leave metric and based on previous 12-month utilization; CM

Health is averaging at 3.00%.

0%1%2%3%4%5%6%

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

Sick Leave Sick Leave LY UCL Average LCL


Annualised CM Health Voluntary Turnover

• Annual Voluntary Turnover for June 2020 is decreasing since March (0.28%) compared to March 2020.

• In comparison to June 2019, Annualised Turnover for June 2020 increased (↑) by 0.69% • Turnover is anticipated to decrease (↓) in the following months due to Covid-19.

CMDHB’s HR team is looking for opportunities to reduce unwanted turnover and analyzing exit reason information and length of service for exiting staff to help develop workforce strategies by retaining key personnel and top performers. Voluntary Turnover by Workforce Group

• This graph represents CMH as a whole and cannot be split to identify Hospital Advisory Committee

only data. • On a 12-month average, highest turnover was recorded for Midwifery group at 15.2%, followed by

Allied Health at 10.1% and Nursing at 9.8%. • Overall CMDHB’s turnover has decreased by 0.7% in comparison June 2019

0%2%4%6%8%

10%12%14%16%

Annualised CMDHB Voluntary Turnover(Hospital Directorate Only)

Turnover Turnover LY UCL Average LCL


Voluntary Turnover Reason Categorisation

Neither Maaori nor Pacifica staff left voluntarily from the Hospital Directorate during the month of June. Below is a list of CM Health Maaori and Pacifica staff that have left and the reason for leaving.

Directorate Reasons for Leaving race ethnic_group_notes HWIP - Final Ethnicity Ethnicity Central Clinical Services PERSONAL SAMOAN Samoan Pacific

Mental Health RETIRE TONGAN Tongan Pacific Mental Health RETIRE NZ EUROPEAN MAORI Maaori Maori Mental Health JOB IN PRIVATE HEALTH SAMOAN Fijian/Indian Fijian Pacific

Women's Health PERSONAL INDO-FIJIAN Fijian Indian Pacific

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Voluntary Employee Turnover by Reason for LeavingJuly 2019 to June 2020 (HAC)

Personal To go overseas Another job in public health ResignedRetired Left district Job in Private health Job outside of healthJob dissatisfaction Education


Involuntary Employee Turnover by Reason for Leaving

There was 1 involuntary employee departure for the month of June 2020.

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Jul-2019 Aug-2019 Sep-2019 Oct-2019 Nov-2019 Dec-2019 Jan-2020 Feb-2020 Mar-2020 Apr-2020 Jun-2020

Involuntary Employee Turnover by Reason for LeavingJuly 2019 to June 2020 (HAC)

Ill health End of contract SSC admin Dismissed Deceased Casual worker


TAS – Voluntary Turnover Analysis

Overall trend in voluntary leavers since 2015

Overall, we see a peak in the number of voluntary leavers in January each year, with secondary peaks around March-April or July-August in some years. Voluntary leavers are permanent staff who ceased employment for reasons other than health issues, death, restructuring, redundancy or dismissal. Leavers have been grouped according to their final date of employment.


Trend in leavers by CCoA group since 2015

The Nursing CCoA group has the largest total number of leavers and has the greatest influence on the overall trend. The trend for Allied Health leavers is similar to Nursing, however, the trend is slightly different for SMOs and Support Personnel, likely due to the smaller number of leavers each month. It may also be that those workforces are more stable, possibly as staff in these groups tend to be at the lowest and highest ends of the pay spectrum.


Interim leavers data for April – June 2020

13 DHBs responded to the request for numbers of voluntary leavers from April to June 2020. When we add this to the data sourced from the HWIP database for the same DHBs, we see a marked variance from the previous trend. While the numbers of leavers increased from April to May 2020 for all CCoA groups, excluding Nursing, it was still well below the January 2020 peak.


Voluntary leavers in 2020

This chart again focusses on the 13 DHBs that provided interim data for the April to June period. While the June leavers may be artificially low, as they were collected prior to the end of the month, they still provide an indication that voluntary resignations are well below where we would expect them to be under normal circumstances.


Organisational Health & Safety Indicators

LTIFR (Lost Time Injury Frequency Rate) LTIFR The 12 month rolling average figure continued to drop down to 9.02 in June 2020. The June 2020 figure (9.02) decreased from the May 2020 figure (9.84). The figures reported below have decreased from previously reported figures due a change in the reporting methodology to include all hours worked within the organization to determine the LTIFR 12 month rolling average figure. The historical LTIFR figures will continue to fluctuate due to possible changes in the overall hours worked (due to directorates getting in hours late to payroll) and an increase in accepted LTI claims (due to the timeframe set by ACC to accept/ decline a claim).

LTIFR - Number of Lost Hours per million hours worked

• This graph represents CMH as a whole and cannot be split to identify Hospital Advisory Committee only data.

• LTIFR (Lost Time Injury Frequency Rate) = (Number of Lost Time Injuries / Hours Worked) x 1,000,000.

Note: • In June, there were 35 new claims registered with 2 lost time claims. • Current claims being managed by the CM Health and WellNZ Case Managers was 111 in June Lost Time Injury Frequency Rate (LTIFR) as an indicator of safety performance. As a means of identifying if businesses are continuously improving and reducing incidents causing significant workplace injury or illness, LTIFR is often used across industry groups. LTIFR is a measurement of safety performance representing; • the number of incidents per month that required the injured person to take days off work for their

recovery • the total number of hours worked across the organisation in that month

11.3111.10

11.4011.17

11.78 11.8812.09 12.12

11.25

10.74

9.84

9.02

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Counties DHB Lost Time Injury Frequency Rate (LTIFR)


Because this figure is very tiny, the recognized calculation across industries is to multiply this figure by 1 million (or 200,000 for some organizations). The calculation for Counties Manukau is therefore; (the number of Lost Time Injuries / total hours worked) x 1,000,000. It should be noted that LTIFR does not mean a safe or unsafe work environment, but it represents a simple way to calculate injuries and illnesses over time and to benchmark and compare the organisation against other similar organisations. As in the above statistics, LTIFR is a Lag Indicator (focusses on past events) whereas Lead Indicators can be implemented to help avoid future incidents. Severity Rate measures how critical the injuries and illnesses were for work related claims. Severity Rate describes the number of actual lost work days including those where medical restrictions are applied (eg alternate duties). Injury Severity Rate = (number of work days lost + light duty days lost) x 1,000,000/ total hours worked Lead and Lag indicators are often used to measure improvements and challenges across the organization however it is worth noting caution must be applied when recording incidents as a lag indicator. The aim is always to ensure all incidents are reported, regardless of their severity so an increase in incidents (and near misses) being reported is generally acceptable. This enables us to focus on our trends and critical H&S Risks. Lead indicators should assist in reducing harm across the organization and should be a big focus for Counties Manukau Health. Increased Lead Indicator reporting should be noted this year.


Organisational Recruitment Indicators

Recruitment – Hired FTE, Headcount and Average Time to Hire in Days

Recruitment – Hired FTE, Headcount and Average Time to Hire in Days Professional Group Average Time to Hire Days Total FTE Offered Number of Candidates Hired

Allied 49.78 19.6 23 SMO/MOSS 51.36 8.4 11 Non-Clinical 39.2 40.47 54

Nursing 95.12 40.8 69 Technical 33.57 11 29 Midwifery 87.17 3.3 6

Totals 62.15 124.57 192 This graph is for CMH including Hospital Advisory Committee *The Time to hire (TTH) includes the full end to end recruitment process from the Time the Vacancy (ATR) has been approved until the candidate accepts the offer online by ticking the acceptance box. There are many steps which include advertising the role, CV screening, Hiring manager reviewing and shortlisting CV’s, interview set up and interview conducted, reference checks, offer of employment process of contract being approved and then the candidate accepting the offer. The process is the same for internal staff moving into another role. New RN’s ,HCA’s, EN’s to CM Health (ie. excluding transfers) Average TTH = 112.48 days

• 18 HCA’s hired at (6.0FTE) 133.47 TTH days (HCA’s tend to work across more than one organisation, often start dates are changed, or the on-boarding process is not completed, which requires follow up, which impacts the TTH.)

• 14 RN’s hired – (11.10FTE) - TTH 71.21 days

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Summary of Annual Leave Cash-ups – Breakdown by Designation (HAC) Data from 01 July 2019 to 30 June 2020

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Number of candidates hired - June 2020

AlliedSMO/MOSSNon-ClinicalNursingTechnicalMidwifery

Designation Month Leave cashed Sum of hrs Sum of Current AL Balance Sum of AL Taken in 12 MonthsREGISTRAR Dec 2019 70.46 88.24 110.46

MOSS Dec 2019 303.16 256.5 476.32MEDICAL OFFICER Dec 2019 40.5 52.87 88.5

COMMUNITY MIDWIFE Feb 2020 241 1151.34 480REGISTERED MIDWIFE Apr 2020 48 220.39 48

CLINICAL MATERNITY CO-ORDINATOR Apr 2020 96 238.85 96WARD CLERK May 2020 56 194.91 257WARD CLERK Jun 2020 56 194.91 257

ADMINISTRATION CLERK Jun 2020 80 322.94 140Grand Total 991.12 2720.95 1953.28

COVID-19 and cancer services

Report 3

Working report on the impact of COVID-19 on cancer services for the period ending

June 2020

August 2020

Te Aho o Te Kahu, Cancer Control Agency 2

Contents

Contents ................................................................................................................................................... 2

Summary of findings ................................................................................................................................ 3

Introduction ............................................................................................................................................. 5

Cancer Registrations ................................................................................................................................ 6

Gastrointestinal endoscopy ................................................................................................................... 11

Bronchoscopy ........................................................................................................................................ 12

Combined curative cancer surgery ........................................................................................................ 14

Colorectal cancer surgery ...................................................................................................................... 15

Lung cancer surgery ............................................................................................................................... 17

Prostate cancer surgery ......................................................................................................................... 18

Medical oncology ................................................................................................................................... 20

Radiation oncology ................................................................................................................................ 22

Haematology .......................................................................................................................................... 25

Appendix 1: NZCR data information ...................................................................................................... 28

Appendix 2: NZCR registrations by DHB ................................................................................................ 29

Appendix 3: Diagnosis and treatment data by DHB .............................................................................. 31

Appendix 4: Surgical procedure codes .................................................................................................. 42


Summary of findings

Overview of impact of COVID-19 on cancer diagnosis and treatment

There has been a substantial increase in new cancer registrations and diagnostic procedures in June

compared to May 2020. This report shows that we are catching up on the dip in cancer registrations seen

over the lockdown period. The overall number of diagnostic procedures and new cancer registrations in 2020

remains lower than 2019. Cancer treatment services – surgery, medical oncology, radiation oncology and

haematology – continued during the COVID-19 lockdown and continue to be delivered at pre-COVID

volumes.

Background and data • This is the third report looking at the impact of COVID-19 on cancer services. This report looks at the

period until the end of June 2020, the first full month out of national alert levels 3 and 4.

• The purpose of this analysis was to rapidly measure the impact of COVID-19 on cancer services to

assist with recovery planning.

• The report focuses on the aspects of the cancer care pathway for which we have readily available

data and does not capture all aspects of the care.

• Comparisons between 2020 and 2019 do not consider any projected increase in diagnoses over time.

• The focus of the report was to understand the impact of COVID-19 on existing service delivery and

does not address pre-existing unmet need.

Cancer diagnosis

Registrations • Overall for the year to date (up until end of June 2020), there have been 689 fewer cancer

registrations compared to the same time period in 2019, a 4.5% decrease.

• There were 225 more cancers registered in June 2020 compared to June 2019, a 9.2% increase.

Māori were the only ethnic group where there remained a decrease in the monthly number of

registrations in June 2020 compared to 2019.

• The decrease in cancer registrations for the year to date was relatively similar across all ethnic

groups. Over the year to date there was a 5% decrease in registrations for Māori, 2.5% decrease for

Pacific and a 5.3% decrease for European/other. There was an increase in registrations for people in

the Asian ethnic group.

• The overall impact on registrations for the year to date has been most marked for

haematology/lymphoid, melanoma and non-melanoma skin cancer, prostate and breast cancers (all

have seen a 10-12% decrease for the year to date).

Diagnostics • Gastrointestinal endoscopy services increased substantially in June 2020, with a 20% increase in

endoscopies performed in June 2020 compared to June 2019.

• Overall, for the year to date there has been 11% fewer gastrointestinal endoscopies performed in

2020 compared to 2019, with Māori having a smaller cumulative reduction (5%) compared to non-

Māori/non-Pacific (12%).


• Despite the 11% decrease in colonoscopies for the year to date, there has only been a 1.8% decrease

in registrations of colorectal cancer. This suggests that triage systems are operating well within DHBs,

with those at highest risk being prioritised to receive their colonoscopies.

• There has been significant work by DHBs to increase the delivery of endoscopies post lockdown.

There is ongoing work nationally to address the demand for colonoscopy services.

• Bronchoscopy services have increased in June 2020 compared to May 2020. There was an increase in

bronchoscopies performed in June 2020 compared to June 2019. However, there remains a deficit

between the number of bronchoscopies performed in 2020 compared to 2019. Overall there were

22% fewer bronchoscopies performed in the first six months of 2020 compared to the first six

months of 2019. This appears to have started prior to the lockdown, with fewer bronchoscopies from

February 2020. Te Aho o Te Kahu is investigating the cause of variance in bronchoscopies in 2020.

Cancer Treatment

Surgery • Overall, the impact of COVID-19 on cancer surgery volumes has been minimal, with 2% fewer

surgeries performed in the first six months of 2020 compared to the first six months of 2019. There

has been an 18% increase in surgery for Māori in 2020 compared to 2019.

• Colorectal cancer surgery returned to pre-COVID volumes in June.

• There was an increase in curative lung cancer surgery in June 2020 compared to June 2019.

• Overall, for the year to date there has been a 5% decrease in curative lung cancer surgeries

compared to 2019. This deficit is smaller than the gap seen at the end of May 2020 (9%). The

decrease in lung cancer surgery follows the pattern seen for bronchoscopies, with the decrease

starting prior to lockdown. This was most noticeable for Māori. Te Aho o Te Kahu is looking into this

further.

• For the year to date there has been a 15% increase in prostate cancer surgeries compared to 2019.

Chemotherapy and radiotherapy • Overall, for the year to date the number of medical oncology FSAs and number of attendances for IV

chemotherapy in 2020 is comparable to 2019. There has been an overall 17% increase in attendances

for IV chemotherapy for Māori during the first six months of 2020 compared to the same time period

in 2019

• Overall for the year to date the number of radiation oncology FSAs in 2020 is comparable to 2019.

• For the year to date there has been a 6% decrease in attendances for radiation therapy. This is

similar for Māori (6%) and non-Māori/non-Pacific (7%). This may be the result of national

hypofractionation guidance. Te Aho o Te Kahu is looking into this further using the Radiation

Oncology Collection (ROC database), which allows for more detailed analysis.

• Overall, for the year to date there has been a 10% decrease in haematology first specialist

appointments compared to the same time period in 2019. One contributor to this is likely to be a

decrease in FSAs for non-malignant, non-urgent indications, deferred as part of the hospital response

framework. These cases may have been managed in primary care.

• For the year to date there has been an 8% increase in IV chemotherapy for haematological

malignancies compared to the same time period in 2019.


Introduction

Purpose of this report This is the third report released by Te Aho o Te Kahu outlining the impact of COVID-19 on cancer services in

New Zealand. This report looks at data through to the end of June 2020.

The report focuses on the aspects of the cancer care pathway for which we have readily available data and

does not capture all aspects of the care. Critical aspects of cancer care, including access to primary care,

radiology and palliative care are not measured in this report.

Data and analysis The data in this report comes from Ministry of Health national data collections. Each section of the report

includes information on where the data is from and any limitations with the data. Numbers in this report

may not match the previous report exactly, due to late coding/submission of data.

It is important to note that the purpose of the analysis is to rapidly measure the impact of COVID-19 and the

recovery on cancer services and does not consider pre-existing unmet need. The report also makes direct

comparisons between 2020 and 2019 and does not consider any projected increase in diagnoses over time.

Key dates Key dates in relation to COVID-19 that may be of use when reviewing the report include:

• 23 March: alert level 3 and hospital alert level framework released

• 26 March: alert level 4

• 28 April: alert level 3

• 14 May: alert level 2

• 9 June: alert level 1


Cancer Registrations

Notes on data • The data come from laboratory reports to the New Zealand Cancer Register (NZCR). This means that

cancers diagnosed without haematology or pathology (e.g. radiology alone) will not be counted in

this analysis.

• ‘Date’ is date of diagnosis on the NZCR – usually the date the specimen was taken from the person

and sent to the laboratory. Analyses include all new provisional and registered cancer events based

on pathology and haematology reports. Data were extracted from NZCR on 29 July 2020.

• Further information on this data is included in Appendix 1.

Results Table 1 shows the change in cancer registrations in 2020 compared to 2019 by month, and the cumulative

impact this has had on cancer registrations for the year to date (up until the end of June 2020). For each

ethnic group except Māori the number of new registrations in June 2020 exceeded the number reported in

June 2019.

Table 1: Absolute number and percentage change in cancer registrations in 2020 compared to 2019 by month, and cumulative year to date

April 2020 May 2020 June 2020 Year to date

Number % Number % Number % Number %

Māori -71 -28.9 -30 -11.6 -28 -10.7 -74 -5.1

Pacific -20 -23.3 -36 -29.8 21 26.9 -14 -2.5

Asian -37 -30.6 -20 -13.1 18 13.5 56 7.5

European/Other -848 -41.2 -403 -17.1 216 11.1 -660 -5.3

Total Population -976 -38.8 -492 -17 225 9.2 -689 -4.5

Note: a small number of reports have ‘unspecified’ ethnicity, meaning the sum of all ethnic groups may not equal the

total population.

Figure 1: Total number of cancer registrations by month and year (left), cumulative number of cancer registrations by month and year (right)


Figure 2: Number of cancer registrations by month and year, by ethnicity

Figure 3: Cumulative number of cancer registrations by year, by ethnicity


Table 2: Changes in cancer registration in 2020 compared to 2019 by month and for the year to date, absolute difference in number of cases and percentage change, by cancer group.


Cancer Group Number % Number % Number % Number %

Breast -205 -56.8 -133 -33.2 -19 -5.2 -243 -11.7

Cervix -85 -47.2 -46 -24.1 19 11.2 75 7.9

Colorectal -91 -34.9 -14 -4.7 -10 -3.7 -29 -1.8

Gynaecology -3 -3.8 -18 -16.2 21 22.8 29 5.1

Haematology and lymphoid -82 -40.4 -69 -29.5 9 4.8 -129 -10.7

Melanoma and non-melanoma skin -312 -53.8 -280 -40.6 45 8.7 -386 -10.5

Other digestive system -33 -24.4 -9 -6 41 38.3 22 2.9

Prostate -148 -51 35 10.1 -22 -6.5 -233 -12.2

Respiratory and thorax -24 -16.6 -9 -6 3 2.5 -35 -4

Urinary system 3 2.7 7 5.7 12 10.3 14 1.9

Figure 4: Number of cancer registrations by month and year, by cancer group


Figure 5: Cumulative number of cancer registrations by year, by cancer group


Table 3: Changes in cancer registration in 2020 compared to 2019 by month and for the year to date, absolute difference in number of cases and percentage change, by DHB of domicile (See Appendix 2 for graphs)


DHB Number % Number % Number % Number %

Northland -20 -19 -13 -10.1 4 3.9 -7 -1

Waitemata -133 -40.9 -101 -25.6 106 40.5 -50 -2.6

Auckland -74 -38.1 -56 -20.5 39 16.9 -71 -5.1

Counties Manukau -81 -37.7 -31 -12.2 36 17.5 -9 -0.7

Waikato -85 -38.1 -32 -13.3 25 13.1 -105 -7.7

Bay of Plenty -34 -23.3 -40 -24.7 -16 -10.3 -65 -7.1

Tairawhiti -22 -61.1 -12 -38.7 8 32 -25 -14.7

Lakes -29 -46 -16 -21.9 -2 -3.4 -20 -5.4

Taranaki -30 -37.5 -45 -40.2 -8 -9.8 1 0.2

Hawke's Bay -37 -41.1 -6 -5.9 -12 -11.3 -62 -10.5

Whanganui -19 -39.6 -7 -13.7 6 14.3 1 0.3

MidCentral -34 -34 3 2.8 5 4.8 52 8.7

Capital & Coast -65 -44.5 -11 -7.1 -2 -1.6 -54 -6.6

Hutt Valley -17 -26.6 -20 -23.5 -8 -9.5 -15 -3.3

Wairarapa -5 -20.8 4 16.7 7 30.4 9 5.8

Nelson Marlborough -44 -41.5 -28 -25.5 2 1.9 -42 -6.8

West Coast -9 -40.9 -14 -43.8 11 73.3 -17 -13.7

Canterbury -89 -32.7 -28 -9.3 -31 -10.4 -73 -4.4

South Canterbury -15 -38.5 -6 -17.6 8 23.5 -4 -1.9

Southern -138 -63 -37 -16.2 45 24.6 -154 -12.7

Key points • Overall for the year to date (up until end of June 2020), there have been 689 fewer cancer

registrations compared to the same time period in 2019, a 4.5% decrease.

• There were 225 more cancers registered in June 2020 compared to June 2019, a 9.2% increase.

Māori were the only ethnic group where there remained a decrease in the monthly number of

registrations in June 2020 compared to 2019.

• The decrease in cancer registrations for the year to date was relatively similar across all ethnic

groups. Over the year to date there was a 5% decrease in registrations for Māori, 2.5% decrease for

Pacific and a 5.3% decrease for European/other. There was an increase in registrations for people in

the Asian ethnic group.

• The overall impact of COVID-19 on registrations for the year to date has been most marked for

haematology/lymphoid, melanoma and non-melanoma skin cancer, prostate and breast cancers (all

have seen a 10-12% decrease for the year to date).


Gastrointestinal endoscopy

Notes on data • Gastrointestinal endoscopy data were extracted from National Non-admitted Patient Collection

(outpatient) and National Minimum Dataset (inpatient) on 27 July 2020.

• Includes colonoscopies and gastroscopies for all indications (i.e. not just cancer).

• Technical information: Gastroscopies (Purchase Unit Code - MS02005), Colonoscopies (Purchase Unit

Code - MS02007), Combined Gastroscopies + Colonoscopies (Purchase Unit Code - MS02014).

Results Table 4: Absolute number and percentage change in colonoscopy and gastroscopy in 2020 compared to 2019 by month, and cumulative year to date



Māori -354 -68% -79 -13% 143 23% -171 -5%

Pacific Peoples -124 -60% 13 5% 89 40% 146 12%

Non-Māori/Non-Pacific -4323 -78% -1246 -19% 1115 19% -4118 -12%

Total Population -4801 -77% -1312 -18% 1347 20% -4143 -11%

Figure 6: Number of gastrointestinal endoscopy procedures by month and year, for the total population (left) and for Māori (right)

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Gastroscopy and colonoscopy procedures -Māori

2018 2019 2020


Figure 7: Cumulative number of gastrointestinal endoscopy procedures by year, for the total population (left) and for Māori (right)

Key points • Gastrointestinal endoscopy services increased substantially in June 2020, with a 20% increase in

endoscopies performed in June 2020 compared to June 2019.

• Overall, for the year to date there have been 11% fewer gastrointestinal endoscopies performed in

2020 compared to 2019, with Māori having a smaller cumulative reduction (5%) compared to non-

Māori/non-Pacific (12%). There has been a 12% increase in gastrointestinal endoscopies for Pacific

Peoples compared to the same time period in 2019.

• Despite the 11% year to date decrease in colonoscopies, there has only been a 1.8% decrease in

registrations of colorectal cancer (see Table 2). This indicates that triage systems are operating well

within DHBs, with those at highest risk being prioritised to receive their colonoscopies.

• There has been significant work by DHBs to increase the delivery of endoscopies post lockdown.

There is ongoing work nationally to address the demand for colonoscopy services.

Bronchoscopy

Notes on data • Bronchoscopy data were extracted from National Non-admitted Patient Collection (outpatient) and

National Minimum Dataset (inpatient) on the 27 July 2020.

• Includes bronchoscopies for any indication (i.e. not just cancer).

• Technical information: Bronchoscopies (Purchase Unit Code - MS02003).

Results Table 5: Absolute number and percentage change in bronchoscopies in 2020 compared to 2019 by month, and cumulative year to date



Māori -25 -83% -19 -43% 0 0% -69 -32% Pacific Peoples* - - - 3 5%

Non-Māori / Non-Pacific -144 -74% -79 -34% 34 25% -234 -22%


*Due to small numbers, monthly figures have not been included for Pacific Peoples

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2018 2019 2020


Figure 8: Number of bronchoscopies by month and year, for the total population (left) and for Māori (right)

Figure 9: Cumulative number of bronchoscopies procedures by year, for the total population (left) and for Māori (right)

Key points • Bronchoscopy services have increased in June 2020 compared to May 2020. There was an increase in

bronchoscopies performed in June 2020 compared to June 2019.

• However, there remains a deficit between the number of bronchoscopies performed in 2020

compared to 2019. Overall there were 22% fewer bronchoscopies performed in the first six months

of 2020 compared to the first six months of 2019.

• Māori were disproportionately impacted by the cumulative decrease in bronchoscopies (32%

decrease for Māori compared to 22% decrease for non-Māori/non-Pacific). This appears to have

started prior to the lockdown, with fewer bronchoscopies from February 2020.

• Te Aho o Te Kahu is investigating the cause of variance in bronchoscopies in 2020.

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2018 2019 2020


Combined curative cancer surgery

Notes on data • This report includes data on curative surgery for colorectal, lung and prostate cancer. These cancers

were chosen because a pre-validated list of surgical procedure codes for these cancers already

existed within Te Aho o Te Kahu, agreed on as part of the quality performance indicator work

programme. These three cancers are therefore used as case studies for cancer surgery more

generally. The procedure codes are included in Appendix 4.

• The data was extracted from the National Minimum Dataset on 27 July 2020.

Results Table 6: Absolute number and percentage change in curative surgery (colorectal, lung and prostate) in 2020 compared to 2019 by month, and cumulative year to date



Māori -6 -15% 2 6% 23 92% 34 18%

Pacific Peoples* - - - -15 -26%

Non-Māori / Non-Pacific -87 -27% 9 3% 5 2% -63 -4%

Total Population -103 -27% 3 1% 24 8% -44 -2%


Figure 10: Number of curative cancer surgeries (prostate, colorectal, lung) by month and year, for the total population (left) and for Māori (right)

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Curative cancer surgeries (prostate, colorectal, lung) - Māori

2018 2019 2020


Figure 11: Cumulative number of curative cancer surgeries (colorectal, lung, prostate) by year, for the total population (left) and for Māori (right)

Key points • Overall, the impact of COVID-19 on cancer surgery volumes has been minimal, with 2% fewer

surgeries performed in the first six months of 2020 compared to the first six months of 2019. There

has been an 18% increase in surgery for Māori in 2020 compared to 2019.

• As noted in the previous reports, the decrease in surgery seen over the lockdown period appeared to

be largely driven by the decrease in diagnostic services.

Colorectal cancer surgery

Notes on data • A list of the surgical procedure codes used for analysis are included in Appendix 4.


Results Table 7: Absolute number and percentage change in curative colorectal cancer surgery in 2020 compared to 2019 by month, and cumulative year to date



Māori -1 -4% 6 40% 12 92% 42 45%

Pacific Peoples - - - -11 -31%

Non-Māori / Non-Pacific -77 -34% -31 -17% -11 -6% -109 -10%

Total Population -87 -33% -29 -14% -3 -2% -78 -6%


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2018 2019 2020


Figure 12: Number of curative colorectal cancer surgeries by month and year, for the total population (left) and for Māori (right)

Figure 13: Cumulative number of curative colorectal cancer surgeries by year, for the total population (left) and for Māori (right)

Key points • Colorectal cancer surgery returned to pre-COVID volumes in June.

• Overall there has been a 6% decrease in colorectal surgery for the year to date compared to the first

six months of 2020. This is likely to be largely driven by the decline in diagnostic colonoscopies

performed during lockdown.

• Overall, there has been a 45% increase in curative colorectal cancer surgery for Māori for the year to

date compared to the same time period in 2019.

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2018 2019 2020


Lung cancer surgery


• The data were extracted from the National Minimum Dataset on 27 July 2020.

• The number of lung cancer surgeries performed each month is relatively small, so caution is needed

when comparing data by month.

Results Table 8: Absolute number and percentage change in curative lung cancer surgery in 2020 compared to 2019 by month, and cumulative year to date.



Total Population -7 -11% 13 23% 7 13% -19 -5% *Due to the small number of surguries performed each month calculations have only been included for the total population rather

than by ethnicity

Figure 14: Number of curative lung cancer surgeries by month and year, total population (left) and for Māori (right)

*Due to the small number of surgeries performed each month it is not possible to draw conclusions from

small changes between months.

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2018 2019 2020


Figure 15: Cumulative number of curative lung cancer surgeries by year, for the total population (left) and for Māori (right)

Key points • There was an increase in curative lung cancer surgery in June 2020 compared to June 2019.

• Overall, for the year to date there has been a 5% decrease in curative lung cancer surgeries

compared to 2019. This deficit is smaller than the gap seen at the end of May 2020 (9%).

• The decrease in lung cancer surgery follows the pattern seen for bronchoscopies, with the decrease

starting prior to lockdown. Te Aho o Te Kahu is looking into this further.

• The early decrease in lung cancer surgery is most noticeable for Māori, with fewer curative surgeries

performed since the beginning of 2020, noting that the numbers are relatively small.

Prostate cancer surgery



• The number of prostate cancer surgeries performed each month is relatively small, so caution is

needed when comparing data by month.

Results Table 9: Absolute number and percentage change in curative prostate cancer surgery in 2020 compared to 2019 by month, and cumulative year to date



Total Population -9 -16% 19 32% 20 33% 53 15% *Due to the small number of surguries performed each month calculations have only been included for the total population

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2018 2019 2020


Figure 16: Number of curative prostate cancer surgeries by month and year, total population (left) and for Māori (right)

*Due to the small number of surguries performed each month it is not possible to draw conclusions from small changes

between months.

Figure 17: Cumulative number of curative prostate cancer surgeries by year, for the total population (left) and for Māori (right)

Key points • For the year to date there has been a 15% increase in prostate cancer surgeries compared to 2019.

There was an increase in prostate cancer surgeries performed in June 2020 compared to June 2019.

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2018 2019 2020


Medical oncology

Notes on data • Extracted from National non-admitted patient collection (Outpatient collection) on 27 July 2020.

• First specialist assessment (FSA) reflects counts of first attendance for specialist medical oncology

assessment.

• IV chemotherapy reflects appointments for outpatient and inpatient IV chemotherapy for non-

haematological indications.

• Technical information: medical oncology FSA (PUC M50020), and IV chemotherapy (PUC MS02009)

Results Table 10: Absolute number and percentage change in medical oncology first specialist assessments in 2020 compared to 2019 by month, and cumulative year to date



Māori -15 -15% -1 -1% 12 12% -3 0%

Pacific Peoples 12 43% -7 -14% -6 -17% 40 20%

Non-Māori / Non-Pacific 87 15% -60 -8% 54 9% 122 3%

Total Population 84 12% -68 -8% 60 8% 159 4%

Figure 18: Number of medical oncology first specialist assessments by month and year, for the total population (left) and for Māori (right)

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2018 2019 2020


Figure 19: Cumulative number of medical oncology first specialist assessments by year, for the total population (left) and for Māori (right)

Table 11: Absolute number and percentage change in IV chemotherapy attendances in 2020 compared to 2019 by month, and cumulative year to date



Māori 118 17% 42 5% 221 33% 735 17%

Pacific Peoples 4 1% -11 -3% 57 22% 45 3%

Non-Māori / Non-Pacific -335 -7% -582 -11% 560 12% 429 1%

Total Population -213 -4% -551 -8% 838 15% 1209 3%

Figure 20: Number of attendances for IV chemotherapy by month and year, for the total population (left) and for Māori (right)

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2018 2019 2020


Figure 21: Cumulative number of attendances for IV chemotherapy by year, for the total population (left) and for Māori (right)

Key points • Overall, for the year to date the number of medical oncology FSAs and number of attendances for IV

chemotherapy in 2020 is comparable to 2019.

• There has been an overall 17% increase in attendances for IV chemotherapy for Māori during the

first six months of 2020 compared to the same time period in 2019.

Radiation oncology

Notes on data • Extracted from National Non-admitted patient collection on 27 July 2020.

• First specialist assessment (FSA) reflects counts of first attendance for radiation oncology specialist

assessment.

• Megavoltage attendance reflects appointments for planning/simulation and for treatment with

radiation therapy on a linear accelerator.

• Technical information: radiation oncology FSA (PUC M50022), megavoltage attendances (Purchase

Unit Code M50025)

Results Table 12: Absolute number and percentage change in radiation oncology first specialist assessments in 2020 compared to 2019 by month, and cumulative year to date



Māori 12 10% 7 5% 22 20% 62 9%

Pacific Peoples 14 47% -15 -29% -16 -36% -19 -7%

Non-Māori / Non-Pacific 46 6% -103 -11% 79 10% 148 3%

Total Population 72 8% -111 -10% 85 9% 191 3%

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Figure 22: Number of radiation oncology first specialist assessments by month and year, total population (left) and for Māori (right)

Figure 23: Cumulative number of radiation oncology first specialist assessments by month and year, total population (left) and for Māori (right)

Table 13: Absolute number and percentage change in radiation therapy attendances in 2020 compared to 2019 by month, and cumulative year to date



Māori -360 -22% -374 -20% 274 17% -550 -6%

Pacific Peoples 32 7% -172 -28% -3 -1% 259 9%



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2018 2019 2020


Figure 24: Number of attendances for radiation therapy by month and year, total population (left) and for Māori (right)

Figure 25: Cumulative number of attendances for radiation therapy by month and year, total population (left) and for Māori (right)

Key points • Overall for the year to date the number of radiation oncology FSAs in 2020 is comparable to 2019.

• For the year to date there has been a 6% decrease in attendances for radiation therapy. This is

similar for Māori (6%) and non-Māori/non-Pacific (7%). This may be the result of national

hypofractionation guidance. Te Aho o Te Kahu is looking into this further using the Radiation

Oncology Collection (ROC database), which allows for more detailed analysis.

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2018 2019 2020


Haematology

Notes on data • Extracted from National Non-admitted Patient Collection (outpatient) and National Minimum

Dataset (inpatient) 27 July 2020.

• First specialist assessment (FSA) reflects counts of first attendance for specialist haematology

assessment for any indication (i.e. not just cancer).

• IV chemotherapy reflects appointments for IV chemotherapy for haematological malignancies.

• Technical information: Haematology FSA (Purchase Unite Code - M30002), IV haem/chemo (Purchase

Unit Code - M30020).

Results Table 14: Absolute number and percentage change in haematology FSAs in 2020 compared to 2019 by month, and cumulative year to date



Māori 0 0% -14 -21% -32 -44% -23 -6%

Pacific Peoples 4 20% -10 -28% 5 16% -14 -9%



Figure 26: Number of haematology first specialist assessments by month and year, total population (left) and for Māori (right)

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Figure 27: Cumulative number of haematology first specialist assessments by month and year, total population (left) and for Māori (right)

Table 15: Absolute number and percentage change in IV chemotherapy attendances for haematological malignancies in 2020 compared to 2019 by month, and cumulative year to date



Māori 30 17% -54 -23% 5 3% 45 4%

Pacific Peoples 31 42% 34 47% 93 160% 144 29%


Total Population -54 -3% -205 -10% 474 29% 868 8%

Figure 28: Number attendances for IV chemotherapy for haematological malignancies by month and year, total population (left) and for Māori (right)

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2018 2019 2020


Figure 29: Cumulative number of attendances for IV chemotherapy for haematological malignancies by month and year, total population (left) and for Māori (right)

Key points • Overall, for the year to date there has been a 10% decrease in haematology first specialist

appointments compared to the same time period in 2019. One contributor to this is likely to be a

decrease in FSAs for non-malignant, non-urgent indications, deferred as part of the hospital response

framework. These cases may have been managed in primary care.

• For the year to date there has been an 8% increase in IV chemotherapy for haematology compared

to the same time period in 2019.

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Appendix 1: NZCR data information

The New Zealand Cancer Registry as a source of data for new cancer

diagnoses Cancer registration is a process where data is collated from multiple sources about people diagnosed with

cancer and rules are applied to determine the type of cancer they have. This information is recorded in the

New Zealand Cancer Registry. Each tumour is classified using an international World Health Organisation

standard so that cancer incidence can be compared between countries. The tumour is staged based on all

the information available within 4 months of diagnosis. This process may take up to six months or more

depending on the number of missing reports that need to be followed up with laboratories.

For each registration there may be multiple pathology reports as there may be multiple procedures

performed on the tumour. This means there will be more than one registration for people diagnosed with

more than one type of tumour.

Cancer registrations come from pathology laboratories, haematology laboratories, mortality records and

reviewing hospital discharge records. Laboratory reports provide the best source of near real time data to

monitor new diagnoses of cancer in New Zealand.

Pathology reports as a data source for providing near real time

monitoring cancer diagnoses Pathology reports (documents) are received by the NZCR as electronic messages. An administrator triages

these documents each day and if the document appears to meet the requirements for registration the

document is “administered”. The document may relate to an existing registration or may contain information

for a new cancer event. Documents that do not meet the cancer reporting requirements will be marked as

“deleted”, “rejected” or “agreed not for registration”.

The administrator creates a new provisional cancer event if the pathology report identifies a new cancer

diagnosis for this person. This new cancer event is assigned to a cancer group and this provisional event is

then queued for further assessment by a clinical coder. If the required information has been provided the

coder creates a new registration. If some information is not yet available, then the registration is held open

until further information arrives to complete the registration or determine that the tumour does not meet

the registration criteria.


Appendix 2: NZCR registrations by DHB


Cancer Registrations by DHB

Total

Māori

European/Other* Cumulative number for

Jan to June Difference between

2019 and 2020

Cumulative number for


2019 and 2020

Cumulative number for


2019 and 2020

2018 2019 2020 Number %

2018 2019 2020 Number %

2018 2019 2020 Number %

Northland 695 671 664 -7 -1

155 113 131 18 15.9

526 540 518 -22 -4.1

Waitemata 1922 1911 1861 -50 -2.6

92 90 111 21 23.3

1591 1588 1470 -118 -7.4

Auckland 1391 1389 1318 -71 -5.1

57 70 51 -19 -27.1

1062 997 991 -6 -0.6

Counties Manukau 1269 1345 1336 -9 -0.7

127 146 168 22 15.1

789 811 773 -38 -4.7

Waikato 1445 1366 1261 -105 -7.7

207 204 166 -38 -18.6

1153 1099 1027 -72 -6.6

Bay of Plenty 879 919 854 -65 -7.1

121 133 113 -20 -15

744 763 722 -41 -5.4

Tairāwhiti 140 170 145 -25 -14.7

41 56 60 4 7.1

99 110 83 -27 -24.5

Lakes 296 369 349 -20 -5.4

76 83 78 -5 -6

204 264 250 -14 -5.3

Taranaki 473 438 439 1 0.2

47 38 39 1 2.6

414 398 394 -4 -1

Hawke's Bay 620 591 529 -62 -10.5

92 95 78 -17 -17.9

504 473 435 -38 -8

Whanganui 276 296 297 1 0.3

34 53 36 -17 -32.1

237 239 254 15 6.3

MidCentral 720 595 647 52 8.7

84 55 59 4 7.3

619 514 560 46 8.9

Capital & Coast 870 814 760 -54 -6.6

56 57 63 6 10.5

694 666 605 -61 -9.2

Hutt Valley 414 452 437 -15 -3.3

47 63 39 -24 -38.1

331 342 358 16 4.7

Wairarapa 192 154 163 9 5.8

20 8 18 10

168 142 138 -4 -2.8

Nelson Marlborough 611 619 577 -42 -6.8 26 28 20 -8 -28.6 573 578 545 -33 -5.7

West Coast 103 124 107 -17 -13.7 5 6 6 0 98 115 100 -15 -13

Canterbury 1658 1674 1601 -73 -4.4

97 80 88 8 10

1465 1512 1405 -107 -7.1 South Canterbury 202 209 205 -4 -1.9

12 9 7 -2

184 199 193 -6 -3

Southern 1048 1213 1059 -154 -12.7

34 70 51 -19 -27.1

983 1123 979 -144 -12.8

Total 15247 15331 14642 -689 -4.5

1430 1457 1383 -74 -5.1

12452 12480 11820 -660 -5.3


Appendix 3: Diagnosis and treatment data by DHB Percentage differences are only presented if the cumulative 2019 total is 10 or greater. In some cases, the grand totals may differ slightly to those

presented in the national report. This is due to non-DHB providers being excluded from the analyses within this appendix.

Gastrointestinal endoscopy Total Māori Non-Māori/Non-Pacific

Cumulative number for Jan to June

Difference between 2019 and 2020





2018 2019 2020 Number % 2018 2019 2020 Number % 2018 2019 2020 Number %

Northland 1771 2056 1447 -609 -30% 288 391 269 -122 -31% 1475 1644 1166 -478 -29%

Waitemata 3919 4390 4006 -384 -9% 207 257 220 -37 -14% 3569 3992 3612 -380 -10%

Auckland 2963 3068 2448 -620 -20% 158 140 139 -1 -1% 2623 2722 2101 -621 -23%

Counties Manukau 3965 4275 5064 789 18% 379 407 509 102 25% 3117 3288 3860 572 17%

Waikato 2521 3153 2946 -207 -7% 304 366 367 1 0% 2176 2749 2532 -217 -8%

Bay of Plenty 2356 2280 2133 -147 -6% 269 304 284 -20 -7% 2077 1969 1841 -128 -7%

Lakes 952 932 787 -145 -16% 175 170 153 -17 -10% 762 750 615 -135 -18%

Tairāwhiti 319 366 308 -58 -16% 87 110 96 -14 -13% 230 253 207 -46 -18%

Taranaki 985 913 833 -80 -9% 97 101 65 -36 -36% 884 807 763 -44 -5%

Whanganui 704 739 575 -164 -22% 108 95 75 -20 -21% 595 642 494 -148 -23%

Hawke's Bay 1200 1414 1264 -150 -11% 131 164 169 5 3% 1057 1231 1075 -156 -13%

MidCentral 1029 1033 1049 16 2% 61 76 94 18 24% 958 947 945 -2 0%

Capital & Coast 1411 1411 1524 113 8% 112 70 120 50 71% 1245 1278 1350 72 6%

Hutt Valley 1116 1505 1496 -9 -1% 89 116 152 36 31% 985 1344 1293 -51 -4%

Nelson Marlborough 467 1215 1177 -38 -3% 22 69 66 -3 -4% 442 1140 1102 -38 -3%

Canterbury 2958 4540 3602 -938 -21% 157 266 204 -62 -23% 2757 4209 3345 -864 -21%

South Canterbury 557 601 567 -34 -6% 24 23 23 0 0% 533 578 543 -35 -6%

Southern 2182 2403 1675 -728 -30% 88 122 93 -29 -24% 2078 2263 1565 -698 -31%

Wairarapa 427 518 381 -137 -26% 35 48 34 -14 -29% 384 466 343 -123 -26%

West Coast 317 294 332 38 13% 22 17 11 -6 -35% 294 276 319 43 16%

Grand Total 32119 37106 33614 -3492 -9% 2813 3312 3143 -169 -5% 28241 32548 29071 -3477 -11%


Bronchoscopy

Total Māori Non-Māori/Non-Pacific


Difference between 2019 and

2020



2020



2020


Northland 44 33 32 -1 -3% 13 11 9 -2 -18% 30 22 22 0 0%

Waitemata 72 78 62 -16 -21% 3 3 6 3 - 65 74 53 -21 -28%

Auckland 148 196 151 -45 -23% 12 19 16 -3 -16% 121 163 119 -44 -27%

Counties Manukau 172 180 171 -9 -5% 36 30 16 -14 -47% 114 122 128 6 5%

Waikato 138 141 94 -47 -33% 29 32 22 -10 -31% 106 107 71 -36 -34%

Bay of Plenty 71 91 65 -26 -29% 13 22 18 -4 -18% 58 67 47 -20 -30%

Lakes 37 46 34 -12 -26% 15 14 16 2 14% 22 31 17 -14 -45%

Tairāwhiti 1 2 14 12 - 1 1 5 4 - 0 1 9 8 -

Taranaki 22 25 18 -7 -28% 4 6 0 -6 - 18 19 18 -1 -5%

Whanganui 3 10 7 -3 -30% 0 5 2 -3 - 3 5 5 0 -

Hawke's Bay 39 40 17 -23 -58% 11 10 2 -8 -80% 28 29 14 -15 -52%

MidCentral 22 18 12 -6 -33% 3 5 1 -4 - 19 13 11 -2 -15%

Capital & Coast 47 48 29 -19 -40% 6 5 5 0 - 38 42 23 -19 -45%

Hutt Valley 43 63 39 -24 -38% 6 13 6 -7 -54% 34 50 32 -18 -36%

Nelson Marlborough 34 33 44 11 33% 4 4 5 1 - 30 29 38 9 31%

Canterbury 167 206 187 -19 -9% 11 21 8 -13 -62% 155 183 174 -9 -5%

South Canterbury 6 6 9 3 - 0 1 0 -1 - 6 5 9 4 -

Southern 119 136 67 -69 -51% 8 12 8 -4 -33% 111 121 59 -62 -51%

Grand Total 1185 1352 1052 -300 -22% 175 214 145 -69 -32% 958 1083 849 -234 -22%


Colorectal cancer surgery




2020



2020



2020


Northland 36 53 43 -10 -19% 6 10 12 2 20% 30 43 31 -12 -28%

Waitemata 137 129 111 -18 -14% 9 10 9 -1 -10% 125 109 99 -10 -9%

Auckland 95 95 97 2 2% 5 6 11 5 - 83 76 82 6 8%

Counties Manukau 79 61 78 17 28% 6 5 15 10 - 64 53 54 1 2%

Waikato 108 106 123 17 16% 12 8 17 9 - 93 97 105 8 8%

Bay of Plenty 70 72 89 17 24% 11 6 12 6 - 59 65 77 12 18%

Lakes 32 41 37 -4 -10% 5 7 7 0 - 27 34 30 -4 -12%

Tairāwhiti 9 15 14 -1 -7% 4 2 3 1 - 5 13 11 -2 -15%

Taranaki 45 45 34 -11 -24% 5 3 4 1 - 40 42 30 -12 -29%

Whanganui 28 25 22 -3 -12% 3 1 2 1 - 25 24 20 -4 -17%

Hawke's Bay 76 74 61 -13 -18% 13 5 9 4 - 63 68 50 -18 -26%

MidCentral 64 54 61 7 13% 5 2 6 4 - 59 51 55 4 8%

Capital & Coast 72 76 71 -5 -7% 5 8 10 2 - 64 65 59 -6 -9%

Hutt Valley 30 28 25 -3 -11% 1 2 2 0 - 27 26 23 -3 -12%

Nelson Marlborough 50 42 33 -9 -21% 0 5 2 -3 - 50 37 31 -6 -16%

Canterbury 159 157 144 -13 -8% 8 8 12 4 - 148 147 129 -18 -12%

South Canterbury 28 26 17 -9 -35% 0 1 2 1 - 28 25 15 -10 -40%

Southern 117 136 102 -34 -25% 6 5 1 -4 - 110 130 100 -30 -23%

Wairarapa 13 9 3 -6 - 1 0 0 0 - 12 9 3 -6 -

West Coast 1 3 4 1 - - - - - - 1 3 4 1 -

Grand Total 1249 1247 1169 -78 -6% 105 94 136 42 45% 1113 1117 1008 -109 -10%


Lung cancer surgery




2020



2020



2020


Auckland 134 141 130 -11 -8% 20 32 21 -11 -34% 106 100 97 -3 -3%

Counties Manukau 1 1 2 1 - 0 0 1 1 - 0 1 1 0 -

Waikato 54 69 85 16 23% 19 22 20 -2 -9% 33 47 64 17 36%

Capital & Coast 57 71 48 -23 -32% 13 11 6 -5 -45% 41 56 40 -16 -29%

Canterbury 40 46 55 9 20% 2 1 3 2 - 38 45 52 7 16%

Southern 16 24 13 -11 -46% 3 0 1 1 - 13 24 12 -12 -50%

Grand Total 302 352 333 -19 -5% 57 66 52 -14 -21% 231 273 266 -7 -3%


Prostate cancer surgery




2020


Difference between 2019

and 2020



2020


Northland 25 26 17 -9 -35% 4 2 5 3 - 21 23 12 -11 -48%

Waitemata 37 31 59 28 90% 1 2 1 -1 - 36 29 56 27 93%

Auckland 44 49 62 13 27% 1 4 4 0 - 40 41 58 17 41%

Counties Manukau 0 0 0 0 - - - - - - 0 0 0 0 -

Waikato 36 35 27 -8 -23% 1 1 1 0 - 35 34 25 -9 -26%

Bay of Plenty 1 2 0 -2 - 0 1 0 -1 - 1 1 0 -1 -

Tairāwhiti 4 2 6 4 - 1 2 2 0 - 3 0 4 4 -

Taranaki 11 12 17 5 42% 1 1 4 3 - 10 11 13 2 18%

Whanganui 2 2 1 -1 - 0 0 0 0 - 2 2 1 -1 -

Hawke's Bay 4 10 9 -1 -10% 0 1 3 2 - 4 9 6 -3 -

MidCentral 35 43 41 -2 -5% 2 5 2 -3 - 33 38 39 1 3%

Capital & Coast 26 30 32 2 7% 1 2 1 -1 - 23 26 31 5 19%

Nelson Marlborough 27 15 23 8 53% - - - - - 27 14 23 9 64%

Canterbury 36 33 39 6 18% 0 1 2 1 - 36 32 37 5 16%

South Canterbury 8 6 9 3 - 8 6 9 3 -

Southern 34 39 48 9 23% 4 2 4 2 - 30 36 44 8 22%

Wairarapa 4 5 4 -1 - 1 0 1 1 - 3 5 3 -2 -

West Coast 4 3 2 -1 - 0 0 0 0 - 4 3 2 -1 -

Grand Total 338 343 396 53 15% 17 24 30 6 25% 316 310 363 53 17%


Medical oncology first specialist assessments




2020



2020



2020


Northland 224 247 203 -44 -18% 59 61 56 -5 -8% 165 183 144 -39 -21%

Auckland 1105 1149 1289 140 12% 132 119 143 24 20% 837 883 964 81 9%

Waikato 425 377 405 28 7% 96 82 89 7 9% 321 285 310 25 9%

Bay of Plenty 224 226 268 42 19% 39 52 45 -7 -13% 184 173 222 49 28%

Lakes 41 89 91 2 2% 17 26 25 -1 -4% 23 62 66 4 6%

Tairāwhiti 41 73 68 -5 -7% 20 29 33 4 14% 21 44 35 -9 -20%

Taranaki 115 107 118 11 10% 10 14 14 0 0% 104 93 103 10 11%

MidCentral 531 510 540 30 6% 80 88 84 -4 -5% 439 413 447 34 8%

Capital & Coast 446 424 438 14 3% 45 56 59 3 5% 370 348 354 6 2%

Nelson Marlborough 226 200 220 20 10% 15 17 10 -7 -41% 210 182 209 27 15%

Canterbury 601 687 638 -49 -7% 40 49 37 -12 -24% 553 629 590 -39 -6%

South Canterbury 1 2 35 33 - 0 0 2 2 - 1 2 33 31 -

Southern 285 367 314 -53 -14% 13 22 17 -5 -23% 271 344 293 -51 -15%

West Coast 14 17 7 -10 -59% 0 2 0 -2 - 14 14 7 -7 -50%

Grand Total 4279 4475 4634 159 4% 566 617 614 -3 0% 3513 3655 3777 122 3%


Medical oncology IV chemotherapy




and 2020



2020



and 2020


Northland 1555 1384 1492 108 8% 287 324 463 139 43% 1250 1048 1014 -34 -3%

Waitemata 0 2 0 -2 - - - - - - 0 2 0 -2 -

Auckland 8347 9620 10930 1310 14% 887 828 1234 406 49% 6543 7563 8439 876 12%

Waikato 3436 3766 3026 -740 -20% 511 621 512 -109 -18% 2884 3102 2463 -639 -21%

Bay of Plenty 2618 2346 2892 546 23% 470 398 582 184 46% 2108 1926 2292 366 19%

Lakes 1310 1503 1501 -2 0% 379 405 462 57 14% 882 1084 1027 -57 -5%

Tairāwhiti 385 289 275 -14 -5% 174 130 133 3 2% 211 159 141 -18 -11%

Taranaki 785 873 1019 146 17% 106 52 102 50 96% 670 810 903 93 11%

Whanganui 69 44 48 4 9% 15 5 7 2 - 54 39 41 2 5%

Hawke's Bay 12 18 46 28 156% 3 3 36 33 - 9 15 10 -5 -33%

MidCentral 3240 3960 3817 -143 -4% 414 747 602 -145 -19% 2753 3094 3166 72 2%

Capital & Coast 3047 3494 3180 -314 -9% 295 341 382 41 12% 2617 2971 2600 -371 -12%

Hutt Valley 61 54 46 -8 -15% 9 2 2 0 - 52 47 39 -8 -17%

Nelson Marlborough 1531 1285 1473 188 15% 138 91 74 -17 -19% 1370 1164 1383 219 19%

Canterbury 3393 2929 3101 172 6% 212 190 202 12 6% 3074 2676 2784 108 4%

South Canterbury 534 533 517 -16 -3% 5 2 11 9 - 529 519 506 -13 -3%

Southern 3285 3642 3564 -78 -2% 198 174 233 59 34% 3069 3446 3274 -172 -5%

Wairarapa 11 5 34 29 - 0 1 8 7 - 11 4 25 21 -

West Coast 6 26 21 -5 -19% 0 0 4 4 - 6 26 17 -9 -35%

Grand Total 33625 35773 36982 1209 3% 4103 4314 5049 735 17% 28092 29695 30124 429 1%


Radiation oncology first specialist assessments




2020



2020



2020


Northland 168 186 133 -53 -28% 51 40 49 9 23% 115 143 83 -60 -42%

Auckland 1591 1547 1563 16 1% 187 190 172 -18 -9% 1206 1173 1218 45 4%

Waikato 674 727 741 14 2% 114 124 161 37 30% 548 587 573 -14 -2%

Bay of Plenty 400 484 459 -25 -5% 57 60 66 6 10% 341 419 389 -30 -7%

Lakes 26 13 6 -7 -54% 5 3 3 0 - 21 10 3 -7 -70%

Tairāwhiti 42 30 26 -4 -13% 16 10 13 3 30% 25 20 13 -7 -35%

MidCentral 901 755 876 121 16% 106 100 118 18 18% 785 646 744 98 15%

Capital & Coast 686 712 665 -47 -7% 67 70 70 0 0% 586 610 565 -45 -7%

Nelson Marlborough 20 112 97 -15 -13% 1 6 7 1 - 19 105 89 -16 -15%

Canterbury 807 772 946 174 23% 37 47 41 -6 -13% 762 712 893 181 25%

Southern 525 482 503 21 4% 28 26 39 13 50% 488 450 456 6 1%

West Coast 3 7 3 -4 - 0 1 0 -1 - 3 6 3 -3 -

Grand Total 5843 5827 6018 191 3% 669 677 739 62 9% 4899 4881 5029 148 3%


Radiation oncology megavoltage fractions




and 2020



and 2020



2020


Auckland 21904 22371 20331 -2040 -9% 2768 3081 2404 -677 -22% 16867 17209 15638 -1571 -9%

Waikato 10382 11441 9697 -1744 -15% 1938 2039 2108 69 3% 8260 9203 7480 -1723 -19%

Bay of Plenty 10226 7247 8131 884 12% 1871 1182 1305 123 10% 8184 6032 6694 662 11%

MidCentral 10528 11810 10841 -969 -8% 1540 1577 1424 -153 -10% 8865 10154 9246 -908 -9%

Capital & Coast 9911 10255 9557 -698 -7% 1034 1039 1098 59 6% 8402 8715 8009 -706 -8%

Nelson Marlborough 0 0 9 9 - 0 0 2 2 - 0 0 7 7 -

Canterbury 14125 11426 11747 321 3% 910 716 775 59 8% 12931 10597 10831 234 2%

Southern 3884 2738 2048 -690 -25% 328 163 131 -32 -20% 3442 2541 1910 -631 -25%

Grand Total 80960 77288 72361 -4927 -6% 10389 9797 9247 -550 -6% 66951 64451 59815 -4636 -7%


Haematology first specialist assessment




2020



2020



2020


Northland 105 112 117 5 4% 17 27 29 2 7% 87 83 87 4 5%

Waitemata 380 311 350 39 13% 16 21 28 7 33% 346 280 307 27 10%

Auckland 483 472 363 -109 -23% 34 37 31 -6 -16% 402 386 288 -98 -25%

Counties Manukau 385 360 280 -80 -22% 36 50 36 -14 -28% 288 258 199 -59 -23%

Waikato 345 386 381 -5 -1% 54 79 63 -16 -20% 285 300 311 11 4%

Bay of Plenty 200 189 148 -41 -22% 33 29 23 -6 -21% 164 155 122 -33 -21%

Lakes 0 2 0 -2 - 0 1 0 -1 - 0 1 0 -1 -

Tairāwhiti 22 15 19 4 27% 9 1 3 2 - 13 13 16 3 23%

Taranaki 70 80 93 13 16% 10 6 11 5 - 60 73 82 9 12%

MidCentral 373 386 361 -25 -6% 49 47 44 -3 -6% 321 335 309 -26 -8%

Capital & Coast 404 371 331 -40 -11% 23 31 38 7 23% 370 324 276 -48 -15%

Nelson Marlborough 116 79 57 -22 -28% 1 4 3 -1 - 114 74 54 -20 -27%

Canterbury 212 269 250 -19 -7% 13 14 14 0 0% 192 247 233 -14 -6%

Southern 140 143 127 -16 -11% 12 7 8 1 - 125 134 118 -16 -12%

West Coast 9 10 1 -9 -90% 1 0 0 0 - 8 10 1 -9 -90%

Grand Total 3244 3185 2878 -307 -10% 308 354 331 -23 -6% 2775 2673 2403 -270 -10%


Haematology IV chemotherapy




and 2020



2020



2020


Northland 970 890 694 -196 -22% 232 187 133 -54 -29% 738 674 534 -140 -21%

Waitemata 1982 1992 1957 -35 -2% 46 81 101 20 25% 1847 1806 1736 -70 -4%

Auckland 1730 1793 1664 -129 -7% 93 129 60 -69 -53% 1465 1450 1451 1 0%

Counties Manukau* 1175 432 1149 717 183 68 103 35 709 305 871 566 Waikato 892 955 1079 124 13% 131 172 206 34 20% 757 781 873 92 12%

Bay of Plenty 590 651 501 -150 -23% 69 48 66 18 38% 521 575 435 -140 -24%

Lakes 10 331 315 -16 -5% 0 97 77 -20 -21% 10 234 238 4 2%

Tairāwhiti 106 50 50 0 0% 10 10 4 -6 -60% 83 40 46 6 15%

MidCentral 1286 1420 1177 -243 -17% 146 164 106 -58 -35% 1119 1256 1065 -191 -15%

Capital & Coast 1492 1685 1595 -90 -5% 22 217 213 -4 -2% 1400 1413 1255 -158 -11%

Nelson Marlborough 0 0 6 6 - 0 0 0 0 - 0 0 6 6 -

Canterbury* 1039 485 1357 872 56 27 159 132 970 458 1171 713

Southern** 110 101 114 13 13% 1 1 20 19 - 109 100 93 -7 -7%

West Coast 4 9 4 -5 - 0 2 0 -2 - 4 7 4 -3 -

Grand Total 11386 10794 11662 868 8% 989 1203 1248 45 4% 9732 9099 9778 679 7%

*Te Aho o Te Kahu are working with Canterbury and Counties Manukau DHB to understand the cause for low volumes in 2019. Number and percentage

differences have not been presented as will not accurately reflect the difference between 2019 and 2020 in these DHBs.

** Note the relatively low volumes in Southern DHB are due to variation in coding which is being followed up on.


Appendix 4: Surgical procedure codes Below is a list of the surgical procedure codes that were used for analysis on curative cancer surgery.

COLORECTAL CANCER SURGERY

Clinical

code Block short description Clinical code description

3200000 Colectomy Limited excision of large intestine with formation of

stoma

3200001 Colectomy Right hemicolectomy with formation of stoma

3200300 Colectomy Limited excision of large intestine with anastomosis

3200301 Colectomy Right hemicolectomy with anastomosis

3200400 Colectomy Subtotal colectomy with formation of stoma

3200401 Colectomy Extended right hemicolectomy with formation of stoma

3200500 Colectomy Subtotal colectomy with anastomosis

3200501 Colectomy Extended right hemicolectomy with anastomosis

3200600 Colectomy Left hemicolectomy with anastomosis

3200601 Colectomy Left hemicolectomy with formation of stoma

3200900 Colectomy Total colectomy with ileostomy

3201200 Colectomy Total colectomy with ileorectal anastomosis

3201500 Total proctocolectomy Total proctocolectomy with ileostomy

3202400 Anterior resection of rectum High anterior resection of rectum

3202500 Anterior resection of rectum Low anterior resection of rectum

3202600 Anterior resection of rectum Ultra low anterior resection of rectum

3202800 Anterior resection of rectum Ultra low anterior resection of rectum with hand

sutured coloanal anastomosis

3203000 Rectosigmoidectomy or proctectomy Rectosigmoidectomy with formation of stoma

3203900 Rectosigmoidectomy or proctectomy Abdominoperineal proctectomy

3205100 Total proctocolectomy Total proctocolectomy with ileo-anal anastomosis

3205101 Total proctocolectomy Total proctocolectomy with ileo-anal anastomosis and

formation of temporary ileostomy

3206000 Rectosigmoidectomy or proctectomy Restorative proctectomy

3209900 Excision of lesion or tissue of rectum or anus Per anal submucosal excision of lesion or tissue of

rectum

3211200 Rectosigmoidectomy or proctectomy Perineal rectosigmoidectomy

9220800 Anterior resection of rectum Anterior resection of rectum, level unspecified

LUNG CANCER SURGERY

Clinical code Clinical code description Block Description

3844000 Wedge resection of lung Partial resection of lung

3844001 Radical wedge resection of lung Partial resection of lung

3843800 Segmental resection of lung Partial resection of lung

9016900 Endoscopic wedge resection of lung Partial resection of lung


3843801 Lobectomy of lung Lobectomy of lung

3844100 Radical lobectomy Lobectomy of lung

3844101 Radical pneumonectomy Pneumonectomy

3843802 Pneumonectomy Pneumonectomy

PROSTATE CANCER SURGERY

Clinical code Block short description Clinical code description

3720004 Open prostatectomy Retropubic prostatectomy

3720900 Open prostatectomy Radical prostatectomy

3720901 Other closed prostatectomy Laparoscopic radical prostatectomy

3721000 Open prostatectomy Radical prostatectomy with bladder neck reconstruction

3721001 Other closed prostatectomy Laparoscopic radical prostatectomy with bladder neck

reconstruction


and pelvic lymphadenectomy

3721101 Other closed prostatectomy Laparoscopic radical prostatectomy with bladder neck

reconstruction and pelvic lymphadenectomy

3720900 Open prostatectomy Radical prostatectomy

3720901 Closed prostatectomy Laparoscopic radical prostatectomy


3721001 Closed prostatectomy Laparoscopic radical prostatectomy with bladder neck

reconstruction


and pelvic lymphadenectomy

1

CAPTURING PATIENT & WHAANAU EXPERIENCE –

APPROACHES IN CM HEALTH

Jo Rankine (CMDHB) [email protected]

2

Contents Introduction ............................................................................................................................................... 3

Current approaches to capturing feedback ................................................................................................... 3

Surveys of inpatient experience ................................................................................................................ 4

Kanohi ki te kanohi approaches ............................................................................................................... 15

CM Health Complaints and Compliments ................................................................................................ 16

Primary Care Setting ................................................................................................................................ 18

Outpatient, ambulatory and community setting ..................................................................................... 19

Appendicies.............................................................................................................................................. 21

3

Introduction CM Health is committed to capturing patient experience and feedback and has invested in doing so for a number of years using a variety of approaches. This paper describes those approaches with some discussion about the benefits, limitations and opportunities. Some examples of the type of data that we can capture is presented and how we use the data to inform service planning and service improvement is discussed.

As the impact of inequity becomes more apparent (WAI 2575) the imperative to capture feedback particularly from vulnerable populations has become increasingly important. We need a range of approaches for capturing patient experience that is not soley reliant on traditional methods of capturing patient experience (surveys) as these do not always meet the needs of the populations we want to hear from most eg Maaori, Pasifika. Having a range of approaches also enables us to triangulate data to strengthen our understanding of patients’ experience.

Current approaches to capturing feedback We utilise a variety of approaches to capture feedback but there are gaps in Outpatient, Community and Ambulatory Care and we are somewhat weighted to survey type approaches. However, we are increasingly using facilitated methods (one to one interviews and focus groups) and are investigating alternative software systems to capture the experiences of patients using Community, Outpatient and Ambulatory services.

Figure 1 Summary of feedback approaches at CM Health

4

Surveys of inpatient experience There are two surveys administered to recently discharged inpatients, a national survey from the Health Quality Safety Commission (HQSC) which is mandatory for all DHB’s to participate in and our own locally developed Inpatient survey. Both surveys have the same patient criteria (overnight stay, aged 15 and over) and are retrospectively administered via email or SMS (mobile phone).

National Inpatient Experience Survey The HQSC survey has been operating since 2014 and is administered quarterly, by a HQSC contracted vendor, using a patient data extract provided by the DHB’s. The quarterly approach means there is a considerable lag time, often up to two quarters. The sample size is set by HQSC at 400 patients per DHB and patients are emailed or sent a SMS invitation to participate. Survey responses are anonymous unless patients wish to discuss their response with the DHB in which case they provide their contact details. Because the survey is mandatory and utilises a common question set, it is possible benchmark nationally. However the small sample size, especially for large DHBs, is problematic as it is not large enough to be representative of the population served. Also, while 400 patients are invited to participate only a small proportion (less than 20%) of them ever respond. While it is possible to drill to ward level data and see verbatim comments the numbers are so low that little weight can be attributed to them.

Improving our response rate and lowest scoring question is a requirement of our Annual Plan and Service Level Measures. However, increasing the response rate is problematic for several reasons. It is challenging to capture up to date email addresses and mobile phone numbers, some people do not have and / or cannot afford a computer / phone and for our ethnically diverse population, face to face methods of capturing information tend to be preferred rather than email / written. Literacy and health literacy factors also impact.

Typically, there are higher numbers of Pakeha that respond to email surveys whereas Maaori, Pacific and speakers of languages other than English tend to be lower. We put considerable effort into capturing email and mobile phone numbers and promoting the national survey but despite this our response rate is consistently lower than the national average (see figure 2). Note: due to a recent change in vendor, the impact of COVID-19 and a HQSC led review of the question set, the survey is on hold and the historical DHB level data has been archived. Accordingly the data available is not current. The change in vendor does offer some opportunities with more timely visbility of results (within two weeks) proposed. However the same sample size and methodology is retained, and is the requirement to improve our response rate. Figure 2 displays our response rate compared to the national average.

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Figure 2 Response Rates (source HQSC website)

HQSC Inpatient Survey Questions

The Inpatient Survey questions take approximately ten minutes to complete and are organised around four quality domains. Informed by the Picker Institute they do allow for some free text however the inability to change or tailor the questions for our environment, or to facilitate deep dives, is a limitation. The four quality domains are:

• Communication • Coordination • Partnership and • Physical and Emotional Needs

Our performance across these quality domains tends to be ‘about the same’ as the other DHB’s with the occassional highs and lows (see figure 3). The question set has been reviewed by HQSC and the quality domains remain the same there is a move away from using the Picker Institute questions. Figure 3 describes our performance across the four domains compared to other DHBs.

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Figure 3 All DHB’s performance across the four quality domains “all ethnicities” (source HQSC website)

The Ministry of Health requires DHB’s to have a work programme to address their lowest performing questions. Consistently for CM Health and our regional DHB partners ADHB and WDHB this has related to information provided to patients about side effects at discharge (figure 4). The 20/21 Service Level Measures Plan requires CM Health, ADHB and WDHB to improve our score by 5% against a similarly worded question to the current one below. The three DHB’s are collaborating in a regional Medication Safety Programme Group which is implementing a range of initatives to improve our performance.

Figure 4 Lowest scoring question HQSC Inpatient Survey (source HQSC website)

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CM Health local inpatient experience survey For approximately seven years CM Health has administered its own locally developed survey through our contracted vendor Cemplicity. To date we have captured approximately 20 thousand patients responses. Like the HQSC survey, it is administered retrospectively via email or SMS and has similar eligibility criteria. However, there is no limit on invitations which means every eligible patient with a current email or mobile number is invited to participate. This does mean that the CM Health data set is larger and therefore it tends to be relied upon to inform service delivery and planning much more than the nationally mandated HQSC survey with its small data size.

It is possible to customise the question set (at a cost) and add a limitted number of additional questions should we want to focus on a particular issue eg hospital parking. The data is visible in real time, and can be analysed by location, professional groups and a wide range of deomographics. The software enable thematic and sentiment analysis. The lack of significant ‘lag time’ is a strength but like the HQSC survey, its approach is reliant on email and SMS and accordingly patients without emails, computers and phones miss out. Surveys are also not ideal for those who prefer face to face or facilitated approaches or where there are literacy, health literacy and language barriers.

Table 1 displays the ethnicity of respondents and as expected Pakeha patients are the largest group of responders.

Table 1 Ethnicity of Responders CM Health Survey August 2019 –July 2020

Ethnicity Responses New Zealand European 63.1% (3491) Maori 20.23% (1115) Samoan 11.4% (628) Indian 10.3.% (570) Tongan 5.4% (300) Other European 4.8 (268) Cook Islands Maori 4.8% (263) Chinese 40.% (223) Other Asian 3.2% (177) Other ethnicity 2.1% (117) Southeast Asian 2.0% (110) Refused to answer 1.9% (104) Niuean 2.3% (1427) Fijian 1.2% (64) African 1.1% (60) Middle Eastern 0.6% (31) Other Pacific Peoples 1.0% (55) Latin American 0.3% (13) Tokelauan 0.3% (18)

Table 2 displays the number of invitations sent, the number started and the number completed. The overall response rate (fully complete the survey) is not as high as wished (YTD total n31681 / n7126 22.49%) but with a much larger group of people responding (YTD n 31681) it is still meaningful. Note there is a bigger ‘drop off’ rate for patients starting and finishing the survey using SMS (YTD 29% start and 17%

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complete) versus email (YTD 32% start and 29% complete). This is true for Maaori respondents as well with 23% starting SMS and 12% completing with email YTD 22% starting and 20% completing)

Table 2 CM Health Inpatient Response Statistics

CM Health Response Statistics – All Ethnicities response statistics

Aug-19

Sep-19

Oct-19

Nov-19

Dec-19

Jan-20

Feb-20

Mar-20

Apr-20

May-20

Jun-20

Jul-20

total

started: email 243 374 447 330 331 373 203 435 269 474 505 501 4485 (32%)

completed: email 220 350 425 310 309 348 193 408 251 437 472 446 4169 (29%)

invited: sms 1661 1689 1701 1502 1476 1454 696 1421 947 1416 1678 1892 17533

started: sms 453 413 443 410 330 285 114 476 350 519 579 634 5006 (29%)

completed: sms 312 272 281 253 215 165 47 276 214 294 309 319 2957 (17%)

CM Health Response Statistics - Maaori Patients response statistics

Aug-19

Sep-19

Oct-19

Nov-19

Dec-19

Jan-20

Feb-20

Mar-20

Apr-20

May-20

Jun-20

Jul-20

total

invited: email 147 168 193 174 214 193 109 197 141 176 178 196 2086

started: email 24 30 49 33 31 44 25 48 31 37 50 50 452 (22%)

completed: email 23 28 48 31 29 44 24 46 29 33 49 42 426 (20)

invited: sms 337 316 337 275 286 272 137 302 192 248 360 392 3454

started: sms 63 48 60 53 43 35 18 92 70 75 116 134 80 (23%)

completed: sms 48 26 36 28 28 16 10 51 41 33 56 52 425 (12%)

CM Health Survey Question Set

The CM Health survey takes between ten minutes to complete. All questions allow free text so patient can give examples and explain why they made their rating. There are ‘core’ questions being Friends and Family Test, Overall Care and Treatment and Fundamental Care questions. Patients can elect to end the survey after completing those or continue on to answer additional questions around the ‘Three Most Important Things’.

• Friends and Family Test question (FFT)

The Friends and Family Test (FFT) is widely used within the UK in health and non health services and is typically positioned at the start of surveys. Asking patients whether they would ‘recommend’ the hospital to loved ones in their hour of need is a significant indicator of satisfaction. If patients wouldn’t recommend “then hospital managers know they have a problem that needs sorting”.1 In CM Health, the FFT is used as a Net Promoter Score (NPS) to track organisational performance overtime. Waitemata DHB is the only other DHB in New Zealand to use the FFT as a NPS.

1 Creating a Revolution in Patient and Customer Experience (NHS)

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Figure 5 describes the results of the FFT ‘How likely are you to recommend our service to friends and family if they needed sinilar care and treatment?’ as the NPS – showing Maaori compared to everyone else from August 2019 – July 2020. The FFT when calculated as a Net Promoter Score (NPS) is 45 for both Maaori in and everyone else in July. However in June it was 20 for Maaori and 38 for everyone else and such fluctuations can be seen over the year. Response rate from Maaori was 704 and everyone else 5422. Figure 5 Friends and Family Test as NPS

• Overall Care and Treatment question

The ‘Overall How Would You Rate Your Care and Treatment’ question is also captured as a NPS. It provides a different perspective from the FFT as the patient is scoring their overall experience (not whether they would recommend / refer). The Overall Care and Treatment NPS (figure 8) in July 9 for Maaori and 37 for everyone else. Response count for Maaori is 708 and everyone else is 5467. Figure 6 shows Overall Care as a NPS over time.

Figure 6 Overall Care as NPS

0

10

20

30

40

50

60

FFT NPS August 2019 - July 2020

FFT NPS Maori

FFT NPS CMDHB

0

10

20

30

40

50

60

Overall Care NPS August 2019 - July 2020

Overall Care NPS Maaori

Overall Care NPS CMDHB

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• Fundmentals of Care Questions section

The Inpatient survey questions about fundamental care are pulled from the Fundamental of Care (FOC) Peer Review which is undertaken six monthly within inpatient services. This has the benefit of using evidence based questions and building a critical mass of responses to the questions. The FOC question set are ‘performance’ based in that patients rate how well we performed when undertaking these activities.

Figure 7 describes the results for Maaori compared to everyone else to the FOC questions across a 10 point scale with 0 being poor – 10 high. The three lowest scores related to food / meeting dietary needs being: the quality of food (5.3 vs 5.4 for everyone else) assistance given to eat (6.9 vs 6.8 for everyone else) and overall dietary requirements (6.9 vs 6.8 for everyone else). The top three scoring aspects related to hand sanitiser use by Doctors (9.3.2 vs 9.4 for everyone else), Nurses and Midwives (9.2 vs 9.4 for everyone else) and Allied Health (9.1 vs 9.3 for everyone else).

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Figure 7 Performance across FOC questions – Maaori versus everyone else August 2019 – July 2020

0 1 2 3 4 5 6 7 8 9 10

Did doctors talk to you about your conditionand treatment in ways that made it easy for…

Did nurses or midwives talk to you about yourcondition and treatment in ways that made…

Did administrative or reception staff talk toyou about your condition and treatment in…

Did other members of your healthcare teamtalk to you about your condition and…

Were you given conflicting information bydifferent staff members?

How would you rate how well the doctors andnurses or midwives worked together?

How would you rate how well staff, such asphysiotherapists, radiographers,…

On a scale of 0 to 10 where 0 is poor and 10 isexcellent, can you tell us how we rated on…

How would you rate the hospital food?

Did staff give you the help you needed to eatyour meals?

Did the food meet any dietary needs that youhave?

On a scale of 0 to 10 where 0 is poor and 10 isexcellent, can you tell us how we rated on…

How clean was your hospital room or ward?

How clean were the toilets and bathrooms?

Did doctors use hand sanitiser or wash theirhands before they touched or examined you?

Did nurses or midwives use hand sanitiser orwash their hands before they touched or…

Did physiotherapists, radiographers, dieticiansor occupational therapists use hand sanitiser…

On a scale of 0 to 10 where 0 is poor and 10 isexcellent, can you tell us how you rated us…

Did you have confidence and trust in thedoctors treating you?

Did you have confidence and trust in thenurses or midwives treating you?

Did you have confidence and trust in thephysiotherapists, radiographers, dieticians or…

Do you think staff did everything they could tohelp manage your pain?

Were you treated with empathy andcompassion?

How would you rate the care and treatmentyou received?

FOC Performance August 2019 - July 2020

CMDHB

Maaori

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• Three things that make the biggest difference to care

On completion of the FOC section patients are offered the option of completing a further section or terminating the survey. If they decide to proceed they are asked to identify the top three things from a comprehensive list of questions that they consider to make the bigest difference to their care. Table 3 lists lists the questions and the percentage responses (Maaori versus everyone). These are not performance related questions as they seek to identify what is most important for patients so we can tailor and plan care for effectively.

Table 3 Three things that make the most difference (Maaori versus everyone) Augutst 2019 – July 2020

Three things Most Important to patients Maaori CMDHB Being treated with compassion, dignity and respect 30.60% 35.60% Communication (discuss care and treatment) 30.10% 33.10% Being involved in decisions about my health and care 28.10% 27.30% Feeling confident about the quality of my care and treatment 29.10% 25.90% Getting good information 25.00% 21.20% Co-ordination of care between the hospital, home and other services (including before admission and after discharge)

18.40% 20.50%

Managing pain 20.40% 18.40% Enabling whānau, family and friends to support me 20.40% 13.80% Other 9.20% 14.80% Respecting my values, beliefs and cultural needs 9.70% 6.30% Managing nausea (sickness) 5.10% 4.40%

For Maaori the top three are:

• Being treated with compassion, diginity and respect was 30.6%. Everyone else (35.6%). • Communication – discuss care and treatment was 30.1%. Everyone else (33.1%) • Feeling confident in care 29.1% and higher than everyone else (25.9%)

There were additional areas where Maaori scored higher than others, such as Being involved in decision making (28.1% versus 27.3%) and:

• Having the support of whaanau, family and friends – Maaori rated this significantly higher at 20.4% versus everyone else at 13.8%

• Respecting values and beliefs and meeting cultural needs – Maaori rated this higher at 9.7% versus everyone else at 6.3%

• Having good information – Maaori rated this higher at 25.5% versus everyone else at 21.2%

Table 4 below gives examples of these themes (positive and negative) using verbatim comments made by Maaori patients who responded to the Three things that make the most difference questions (source CM Health Inpatient Patient Experience Survey).

Table 4 Three Things - Maaori patients verbatim comments August 2019 – July 2020

Compassion, respect, dignity

“I felt I was off concern to them. I never felt I was being neglected it ignored”. “Middlemore did an amazing job and I am truly grateful for being in their care. I

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cannot speak highly enough of the people”. “I fully disliked it when the anesthesiologist asked me to remove my gown in the op room in front of many. Next time put me to sleep 1st!! Worst experience ever. I was pleased when my doctor held my hand as I fell asleep ❤”. “I was asked 8 times if I tried meth. I said no and the doctors said "are you sure?" I found this question offensive as I have never done drugs..” “The nursing staff who looked after me were fabulous, i found them to be friendly and caring. A couple of the doctors were a little abrupt, he pretty much talked to the other doctors and not me so, I didnt know what was going on. …”. “Staff (need to) to take time to talk slowly and accurate, not see patients as numbers”.

Communication “Just the indecisiveness & the time it took to get responses from doctors especially when your nil by mouth, waiting for updates to tell family what’s happening was frustrating…”

“The nurses at Middlemore were lovely and very helpful and treatment of my presenting condition was well managed. However on 3 occasions I asked different health professionals to address a persistent cough I developed which were ignored and I had to return to an afterhours doctor for treatment the day after I was discharged”.

“Doctors and nurses are very busy and have many patents to see or tend to. We need to understand that we are not they only patient in the ward. But sometimes we could be given that extra minute”.

“Doctors are in and out. Talk at the end of the bed but forget we are people in a stressful situation and need to be told what's going on, in a clear and concise way. They use a lot of jargon without explaining. I had to ask them questions as they were walking out and was never asked if I had any questions. The nursing staff were amazing! Filled in all the blanks and went over and above to care for my son and make sure we were okay. The doctor who discharged us taught me more than I had been told in 15mins than the week we were in hospital. He was awesome”.

Confident in care

“IT was really good from the get go but then the nurse had to double check medication after mum double checked with her. Luckily enough she did cos dad was supposed to have two doses and not just the one”. “Trusted the word from doctors and midwives as they both were saying the exact thing nothing different”. “The shift doctor tells you one thing and tells your surgeon something different; the ward doctors don’t actively listen to you and are either walking off or mentally checked out”.

Support from whaanau

“I loved having my mother there to comfort care and help & support me, it was very excellent allowing her to be able to be my female supportive during my stay, it was very helpful also having her there with me every step of the way”. “It made me feel at ease to know a family member heard the same information as I did”.

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Family and friends are an integral part to recovery or wellbeing of the patient/s. It is essential that cultural customs are also exercised where appropriately needed and respected for all”. “I needed my mother to stay the night with me but she was told to go home being maori I am not use to this and needed my mother”. “Whangarei hospital or NDHB have a fantastic whanau support program. I understand Middlemore is on a different scale but it wouldn't hurt to look”.

Values and beliefs, cultural needs met

“I liked that there were Brown nurses and kai awhina at Counties Manakau, it made me feel safe and understood”. “Maori follow tikanga Maori dont do things alone including decisions and isolation Maori whanau is paramount for patients at all times! Hospitals still struggle to understand this. “Hospiral needs to act on Cultural awareness. Hire me, I can teach you how”. “When ask to see a maori advisory i saw her on the day i was going home. 6 days after the request…” “Affective communication with patients, holistic health and well-being. The Nurses should learn more in regards to maori culture, customs and practices, I found that highly offensive, surrounding the security and nurse stepping on my mauri and mana”. “The whole surgical team came out to greet my sister before they started the operation. Amazing”..

Information “We felt well supported and well informed except for the day that we were supposed to be discharged, it would be better to tell patients you will probably not be discharged until the afternoon, I was told we would be able to leave in the morning and then we waited until 4pm which was difficult with planning other children, work and other commitments”. “The doctor who discharged me, I asked about my situation and diet/foods etc and she said just google it, maybe she was in a hurry and too busy”. “I would've appreciated more information be provided before the surgery, on what the surgical process is. I was only provided a date and time to check in to the surgery centre, and from there on, i had no idea what would happen. … The process itself was fine, and all staff communicated each step at the time, however, i wouldve appreciated an overall process as this was my first surgery and knowing the overall process wouldve reduced my anxiety”.

Point Research Insight Reports Approximately eight ‘deep dive’ reports using CM Health’s inpatient survey data are produced annually by Point Research Associates. Recent ‘deep dives’ into our data have been focused on the importance of fundamental care for patients. Appendix 1 contains two recent reports exploring fundamental care from the patients perspective. Part 1 is“Establishing the Relationship” and Part 2 “Integrating Care. A third report (The Context of Care) is in production. Parts 1 and 2 highlight the importance of establishing

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positive and trusting therapeutic relationships with patients, and providing fundamental care in an integrated way.

These ‘deep dive’ reports are tabled at the Clinical Governance Group, Patient and Whaanau Centred Care Board and CM Health’s Consumer Council for discussion. They are ciruclated widely and are also presented at Charge Nurse Forums. They are published on our external website where they are available for the public to view.

Kanohi ki te kanohi approaches

Fundamentals of Care peer reviews The Fundamentals of Care (FOC) is a conceptual framework that involves the establishment of a trusting relationship with the patient to ensure their essential physical, psychological and relational needs are addressed and received. The aims of the FOC programme are twofold, firstly to ensure the consistent delivery in the fundamental aspects of care and to remove barriers to achieving consistent care. Secondly, to provide wards with a framework and data to identify quality improvement initiatives. Every six months a peer review is undertaken against the FOC standards being: communication, clinical monitoring and management, care environment, comfort and pain management, respect, privacy and dignity, nutrition and hydration, safety and prevention, personal care and self- care. “Part A” of the peer review captures patients’ experiences through a one to one interview consisting of 74 questions. Five patients per ward are randomly approached to participate with care taken to include representation from Maaori, Pacific and Asian patients. In the March 2020 peer review 20.8% Maaori participated, 29.4% Pacific, 6.9% Asian, 38.4% New Zealand European and 4.5% identified as Other. March 2020 was the fifth peer review including forty six inpatient areas. Previously, forty one (2019) forty (2018) and thirty-four (2017) wards participated. CM Health’s performance over time across all nine standards is in table 3 below. Following each review Charge Nurse Managers identify and implement improvement activities relating to their results which are reviewed by the FOC Nurse Consultant. FOC results are published widely including being shared with the CM Health Consumer Council. Table 5 CM Health organisational results by part 2017, 2018, 2019 and 2020

In Your Shoes – listening events In Your Shoes (IYS) methodology is a useful approach for gathering patient feedback about their experiences receiving care. it is particularly suited to patient populations that prefer face to face and facilitated interactions. IYS workshops combine ‘one to one’ as well as group work interactions - staff are paired with patients and are ‘listeners’. The insights staff gain in their role as ‘listeners’ can provide organisational benefits beyond those provided by other standard focus group approaches. For patients, they report feeling heard and enjoy not having to compete with other voices which sometimes occurs in group settings. Embedding the IYS methodology is an objective in the Patient and Whaanau Experience Plan. Two IYS workshops were held in 2019 on Visiting and Implicit Bias. An additional workshop with both staff and patients as participants was held to co-design solutions to visiting. The Visiting workshops were prompted

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by feedback received via the inpatient survey, complaints and compliments system and incident reporting system. These workshops were instrumental in shaping the review of the Visiting Policy and development of a new Visiting Procedure both of which include a greater focus on patient and whaanau participation. The Implicit Bias Workshop topic was prompted by the theme for Patient Safety Week in 2019. Two In Our Shoes (IOS) workshops were also held to capture the experience of staff on both those topics. The IOS follows a similar format to the patient workshops. Co design Co-design is a process that enables those who deliver services and those who receive services to create improvements together. Healthcare staff have extensive knowledge to offer on the clinical or technical aspects of care and patients, as the recipient of the service, have extensive knowledge about how it feels to experience the process as it is delivered to them. Co-design uses the contributions of both parties which leads to better understanding of the current process and increased ability to create the most effective improvements for the future. A recent example of this is the Tiaho Mai rebuild.

CM Health Complaints and Compliments Complaints and compliments are an example of unsolicited feedback whereby patients and whaanau can raise their concerns, or compliment on good care, at any point whether it relates to outpatient, ambulatory, community or inpatient care. It is helpful but not mandatory for complaints and compliments to be documented and a Feedback Form is available in clinical and public areas for this. However patients can be reluctant to attach their name to complaints. Complaints can be kept anonymous if wished however it is difficult to investigate and address concerns when the complainant’s details are unknown.

Patients and whaanau can get support from the Health and Disability Commissioner Advocacy Services should they wish or have family support / representation. There are some limitations of the complaint and compliment process – patients’ reluctance to criticise care is one and literacy, health literacy and language issues are the other as the process invariably involves documentation.

Figure 8 displays the types of complaints logged by Maaori patients and whaanau May 2019 – June 2019. The top five concerns for Maaori and whaanau YTD are courtesy, respect and helpfulness, communication, care during tests / treatment, respect and values and treatment delays.

Figure 8 complaint themes – Maaori patients and whaanau May 2019 –June 2020 (source CM Health Feedback Central)

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0 5 10 15 20 25 30 35 40 45 50

Incorrect InformationPrivacy of Communications

Personal SafetyVisitor Numbers, Frequency and Timing

Maintenance of FacilitiesTransfer of Care

Eligibility - determinationAccommodation for Family/Friends

DiagnosisTimeliness of Food Delivery

Appropriate AccommodationTransfer of Discharge Information to Carers

Accuracy of Food Items and Appropriateness of…Freshness, Taste and Temperature of Food

Accidental LossDelay in Test Result

Technical Skills of StaffStaffing Levels

Communication Between Members of Care TeamIncorrect Procedures

Adverse EventsAbility to obtain appointment after referral

SmokingDischarge Instructions and Information

Arrangements for DischargeCoordination of Care

Cleanliness of EnvironmentCultural Sensitivity

Waiting ListPatient Readiness for Discharge

Pain Management and InterventionsParticipation in Care

Waiting time in Waiting AreaProvision of Personal Care to Patient

ResponsivenessInformation, Explanation and Willingness to…

Delay in TreatmentRespect for Values, Preferences & Expressed Needs

During Tests/Treatments/CareCommunication with Family Members and Patients

Courtesy, Respect and Helpfulness

Count of File ID

Cate

gory

Complaints per Category

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Figure 9 describes the compliments we have received from Maaori patients and whaanau May 2019 – June 2020. Note the highest number of compliments is the same as for complaints - courtesy, respect and helpfulness. The next highest is care during tests / treatment, participation in care, respect and values and communication – the last two categories also being the same for complaints. People complain about what is important to them and likewise praise what is important, so it is expected that there is some crossover of themes.

Figure 9 Compliment themes by Maaori patients and whaanau May 2019 –June 2020

Primary Care Setting Following the implementaiton of the naitonal inpatient survey HQSC developed a primary care survey which uses the same quality domains as the inpatient survey. Like the naitonal survey, it is retrospective and reliant on email and SMS invitations. Participants are sent a link to the survey following a consultaiton with a general practice. Like the HQSC Inpatient Survey there is invariably a significant lag of one or two quarters before the results become visible. The HQSC review of questions, COVID and change in vendor has also impacted on the Primary Care Survey results so currently there is limited information available on their website and results only available for Q2 (2019). Figure 10 describes the results across the four quality domains of communication, coordination, partnership and physical and emotional needs.

0 20 40 60 80 100 120 140

VisitingWaiting Area Issues

Waiting ListWaiting time in Waiting Area

Accuracy of Food Items and Appropriateness of…Covid-19 related

Cultural SensitivityTechnical Skills of Staff

Cleanliness of EnvironmentResponsiveness

Freshness, Taste and Temperature of FoodInformation, Explanation and Willingness to…

Coordination of CareProvision of Personal Care to Patient

Communication with Family Members and…Respect for Values, Preferences & Expressed…

Participation in CareDuring Tests/Treatments/Care

Courtesy, Respect and Helpfulness

Count of File ID

Cate

gory

Compliments per Category

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Figure 10 Primary Care results by domain Q2 2019 (Source HQSC website)

Outpatient, ambulatory and community setting Currently, there is not a survey option for capturing outpatient, Community and ambulatory patient experiences. However good use is made of the complaint and compliment system, focus groups and patient interviews to inform service delivery and planning eg Booking and Scheduling Review. However more is needed and planned for such as a survey approach appropriate for community, outpatient and ambulatory care settings and the extention of the FOC programme into the community, outpatient and ambulatory settings. The development of Health Park provides some opportunity for capturing patient experience using approaches such as surveys (email, facilitated), and Happy / Not Happy (Smiley Face) terminals and IYS.

Discussion

There are some gaps in our approaches and ability to comprehensively capture patient experience data. The Patient and Whaanau Experience Plan has as an objective ‘the implementation of a comprehensive system to capture the experience of all populations across the DHB,’ which is PREMS (Patient Reported Experience Measures) and PROMS capable (Patient Reported Outcome Measures). Alternative vendors (ADHB and WDHB) have been investigated that would facilitate outpatient, community, and ambulatory services participation as well as PREMS and PROMS.

Currently the largest volume of data comes from our own inpatient suvey, the Fundamentals of Care Programme and complaints and compliments. However as noted earlier, the data displayed in this report is not fully representative of all the data we are able to collect and report but was selected to provide some context Although it is not a comprehensive data set it does show that patients’ ethnicity (and no doubt other demographics) impact on how they experience our care. While only organisation level data has been

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presented in this report all Charge Nurse Managers and Clinical Quality and Risk Managers have access through their logins to their ward / service level data meaning they can respond to the data at a local level, use for their improvement projects, planning and service development. They can compare their performance and the experience of their patients with the rest of the organisation.

Patient experience data contributes to the DHB’s development of strategy and plans eg Nursing Strategy and Patient and Whaanau Experience Plan and there are many projects underway that use data to improve patient experience. The Patient and Whaanau Centred Care Board, the CM Health Consumer Council, the Quality, Monitoring and Improvement Group and Clinical Governance Group are examples of organisation wide committees / groups that are provided with reports on patient experience. In 2019 Te Pae Whakawhanaungatanga was established by the Chief Nurse & Director of Patient and Whaanau Experience which has eqitable and relational care and the development of Maaori models as its core purpose which is a strong driver of patient experience. See excerpt from its Terms of Reference below:

Purpose “The delivery of equitable care requires a paradigm shift from a bio-medical model of care to one which is mana-enhancing for all. There is a cultural imperative to establish meaningful effective relationships with service users to enable health care providers to deliver effective care in true partnership.

A number of Maori models of care exist; eg Te Whare Tapa Wha (Durie, 1988) which have not been widely used/implemented or documented to be in use in mainstream services. This group seeks to explore the landscape of those in theory and use, identify relevant evidence and implementation. There will be training, education and research and evaluation implications including the use of co-design. This work will span all settings, professions and staff groups”.

The work of the above groups and the many local and organisational project workstreams utilise the concerns and insights that are captured in our patient experience data.

Conclusion

This paper outlined a range of approaches CM Health has in place for capturing patient experience and gave some examples of data captured. The approaches are not as comprehensive as we would wish with some services and populations unable to participate but we are using facilitated approaches more frequently, and investigating ways in which we can more comprehensively capture patient experience. The experience insights that we are currently able to capture do inform service delivery and planning.

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Appendicies Appendix 1 - Point Associate Report using CM Health Inpatient Survey data

Counties Manukau Health Inpatient Experience Report no.1 May 2020:1

Inpatient Experience Fundamentals of Care: Part 1 May 2020

part 1: ESTABLISHING THE RELATIONSHIP

Fundamentals of care is a conceptual framework that involves 3 components; 1) establish the relationship 2) the integration of physical, psychological and relational care needs and 3) within the context of care. The core of the framework rests on the ability of the healthcare practitioner to establish a relationship and make explicit their commitment to care. This requires a connection with the patient so that fundamental care needs can be met.

The first part of the framework, establishing positive and trusting therapeutic relationships with patients, has long been recognised as an essential component of healthcare practice, and patients who say they have good relationships with their care team report a significantly better experience in hospital. Many of you likely understand the concept of whanaungatanga, which describes relationships that occur through shared experiences and working together which provides people with a shared sense of belonging. Whakawhanaungatanga (literally, to do whanaungatanga) describes the process of creating and maintaining the relationship. This is also one of our four DHB values and speaks specifically to what is involved in establishing good relationships and nurturing ongoing connections with patients and consumers by all health disciplines and staff. Establishing the relationship or whakawhanaungatanga is explored in this report using five key elements* of our commitment to care to make this explicit.

We understand that it isn’t always easy to establish positive and trusting relationships. Various challenges in clinical practice, such as lack of time and resources, demand, or systems issues can make it increasingly difficult to deliver effective care centred on relationships. We also know, however, that good relationships lead to a better care environment and better patient safety. To gain an understanding of what this process looks like from patients perspectives, we have used qualitative data from the Patient Experience survey for the 12 months from March 2019 to March 2020 to identify what it looks like when the process works well, as well as some of the challenges and barriers.

Our aim is that you can use these examples to reflect on your own practice and experience in providing authentic and effective care for our CM Health patients.

Jenny Parr Chief Nurse and Director of Patient and Whaanau Experience *1) developing a trusting relationship with the patient; 2) focusing on them and giving them your undivided attention; 3) anticipating their needs or concerns; 4) knowing enough about them to act appropriately; and 5) evaluating the quality of the relationship (Kitson et al 2013).

REFERENCES Kitson, A, Conroy, T, Kuluski, K, Locock, L & Lyons, R 2013, Reclaiming and redefining the Fundamentals of Care: Nursing’s response to meeting patients’ basic human needs, Adelaide, South Australia: School of Nursing, the University of Adelaide. Feo R, Conroy T, Jangland E, et al. Towards a standardised definition for fundamental care: A modified Delphi study. J Clin Nurs. 2018;27:2285–2299. https://doi.org/10.1111/jocn.14247 Counties Manukau Health (2019) Fundamentals of Care Report. Accessed 7 March 2020 from https://countiesmanukau. health.nz/about-us/performance-and-planning/quality-accounts/fundamentals-of-care-report/ Kaldal. M.H., Kristiansen, J., Voldbjerg S. L. (n.d.) The conceptual ”Fundamentals of Care” framework as a reflective tool to improve nursing students’ communicative and relational competencies. Accessed 7 March 2020 from https://www.ucviden.dk/ portal/files/52230536/A0_Fundamentals_of_Care_TRYK.pdf

http://www.ucviden.dk/

http://www.ucviden.dk/


FUNDAMENTALS OF CARE REPORT PART 1: ESTABLISHING THE RELATIONSHIP

1. BUILD TRUST

BEGIN WITH AN INTRODUCTION The [doctor] did

Patients tell us that a trusting relationship begins when staff introduce themselves and briefly outline the role they will play in their care and treatment.

The medical staff would always introduce themselves and ask how I would like to be addressed, Mister, or Christian

name. (NZ European patient)

not introduce himself so I had to ask him if he was my doctor.

(NZ European patient)

BE CALM AND REASSURE For many patients, clinical settings are an unfamiliar and unsettling environment. Patients appreciate it when we check to see how they are coping and reassure them

Each person that came to see me would ask how I was coping and offered reassurance if and when I needed

it. I was grateful for as this showed me that they really take care of their patients and listened to me. (NZ

European patient)

when they are worried. They say when we do this it makes them feel valued, safe and that they are in the right place.

Some nurses spoiled it for the rest. They treated me like I should know what I need to be doing and felt like they didn’t want to be there or help me and made me feel uncomfortable and not worth their time or effort.

(Maaori patient)

ASSESS and build on HEALTH LITERACY Actively engaging the patient and drawing on their perspective of what it means to be ill is not only the beginning of a trusted relationship, it is also an effective way of assessing how the patient is feeling, their level of understanding of their condition, and where they might need more information.

The entire team would discuss the next steps with me, checking often that I had a complete understanding of the next procedure or step that may be coming up. They would listen to all of my concerns and address them in a

way that ‘made sense’ to me. (Maaori patient).

The consultant didn’t explain the rationale for treatment, [they] pretty much told me to take a medication for

the rest of my life and walked out, no indication why or explanation. Felt like [they] didn’t care. (Maaori patient).

I was offered the wrong medication on a number of

occasions, urgent medication was not ordered when charted and there was a 24 hr delay in receiving it. For 4 days a nurse gave me [the wrong dose of my medication]. (NZ European patient)

[Staff] were patient and in good spirits. They

gave clear instructions, explained the situation, supported me through the whole process and checked in regularly.

They went above my expectations and I felt in very safe hands and confident I was being

well looked after (‘Other’ ethnicity).

PRIORITISE SAFETY Our patients trust that we have the right knowledge, skill and expertise to know how to keep them safe from any harm, and many tell us that at CM Health they feel “in safe hands”. For some, however, this trust is compromised when staff openly disagree with each other, when mistakes are made with medication or when a patient has an adverse reaction to blood collection or PICC line insertion (e.g. pain, bruising).



2. Be FOCUSed

ATTEND TO THE HIDDEN STUFF Comments from a number of patients would suggest that they are highly attuned to the ‘hidden’ parts of interactions. Body language, unconscious bias, and even the choice of location can influence how a patient feels about an interaction. Examples of negative interactions include eye rolling, glancing at a watch, answering a phone, speaking to others as though the patient isn’t there or having private conversations in a public space.

I never once sensed anything negative like sighing, eye rolls, mumbling, body language or anything between staff that could have made me slightly

uncomfortable. (NZ European patient)

Most of the time doctors spoke more to the team they were with rather

than me and so I was confused about what was going on. (Maaori patient).

3. ANTICIPATE

STAY ONE STEP AHEAD Being one step ahead of patients’ needs, particularly around pain management, physical comfort and information contributes towards a positive experience for patients.

[The nurses] anticipated needs before I

articulated them, were confident in what

they were doing, and treated me with huge

compassion and dignity. (NZ European patient).

When I told a nurse I was in pain, they did

not get back to me. Said that I have to wait 30 minutes but never came back at all, it happened twice to me during my

stay. (Maaori patient).

ANTICIPATE SUPPORT NEEDS We heard from a number of patients who found it difficult to complete basic tasks such as showering, eating or toileting on their own at different times during their hospital stay, and who felt healthcare staff assumed they could do this for themselves. Anticipating and assessing what patients can do for themselves, and what they might need support with can help greatly with patients’ feelings of trust and safety.

When I need assistance the nurses on duty were able to answer the bell and even help with what I needed.

They were so mindful and ask if I need anything else and check on me.

(NZ European patient)

I felt unsafe, there was lack of staff to help with showering and keeping clean. I always had to ask for help it was never offered.

(Maaori patient).

ACTIVELY ENGAGE Our patients report a more positive experience when they feel staff have been able to actively engage them and give them undivided attention for short bursts of time without distraction. Being able to focus in this way is hugely important in terms of surveillance, anticipation and detecting changes.

Though the doctors were busy they gave me undivided attention when I

needed it. (Ethnicity not stated).

The Doctor I saw was abrupt and seemed more concerned about his students then me. (Maaori patient).



4. KNOW

ENGAGE IN CULTURALLY SAFE WAYS Patients say that when staff know enough about them to be able engage in a culturally safe manner they feel ‘seen’ as a human being. Some tell us of their appreciation of staff who value their worldview and life experience, and who use this to establish a trusting relationship and guide their interactions. Whilst cultural safety is far more complex than small gestures, in practice, many of the actions patients appreciate are extremely simple. These include checking name pronunciation, ascertaining how people would like to be greeted and respecting cultural practices around nudity and the return of body parts.

I don't want my body to be exposed to any males. This is a culture and religious issue.

(Asian ethnicity).

Awareness of my cultural beliefs and values is

important to me and my whaanau. Staff were really friendly and helpful people.

However, their understanding of tikanga/kawa was very

limited. (Maaori patient).

5. EvaluatE

INCLUDE WHAANAU ON THE TEAM Whaanau can offer insights and solutions that can help the care team evaluate and determine the abilities of the patient to self-manage. Many of our patients tell us that involving their whaanau and support people in their care (and decisions around their care) is particularly important. For many, this reflects the fact that whaanau, family carers and other support people are their most important source of long-term support.

If there was anything that myself or my whanau needed to know or needed, it

was never ever a problem so I rate it a 10. (Maaori patient).

Be good to let the support person have a say and something decent to rest on if requested because they are important to

my care. (Maaori patient).

REVIEW AND FEED BACK Patients appreciate it when their healthcare team continuously reviews progress and gives feedback as to how things are going, checking that they understand what is happening and are aware of next steps.

Even though I saw I found that different doctor having a different teams everyday, midwife every

the care was shift meant re- consistent. I didn’t introducting my

have to repeat concerns every myself. time.

(NZ European patient). (Maaori patient).

RECORD AND READ Patients appreciate when we approach them with some knowledge of them and their condition. They get frustrated when they have to repeat the same information to numerous staff.

The entire team would discuss with me the next steps with me, checking often, that I had a complete understanding of the next procedure or step that may

be coming up. (NZ European patient).

I left the hospital still unsure about the seriousness of one of my conditions and what I

need to / can do to manage the condition. (NZ European patient).

Counties Manukau Health Inpatient Experience Report no.2 July 2020:1

Fundamentals of Care: Part 2 July 2020

Inpatient Experience

REFERENCES Conroy, T., Feo, R, Alderman, J and Kiston, A (2016), Building nursing practice: the Fundamentals of Care Framework.

Counties Manukau Health (2019) Fundamentals of Care Report. Accessed 7 March 2020 from https://countiesmanukau.health.nz/about-us/performance-and-planning/quality-accounts/fundamentals-of-care-report/

International Learning Collaborative “The Fundamentals of Care” (Updated 12 April 2019) https://intlearningcollab.org/mission/the-fundamentals-of-care/

Kitson, A & Muntlin Athlin, Å (2013) Development and Preliminary Testing of a Framework to Evaluate Patients’ Experiences of the Fundamentals of Care: A Secondary Analysis of Three Stroke Survivor Narratives. Nursing Research and Practice https://doi.org/10.1155/2013/572437

part 2: INTEGRATION OF CARE

The Fundamentals of Care framework describes how best to deliver relationship-based, integrated, fundamental care. It supports the healthcare team to get fundamental care right and ensure no fundamental care need is neglected.

Whilst it isn’t easy, fundamental care is essential to wellbeing. This is demonstrated often in stories told to us by respondents to our patient experience survey. Those who have an excellent experience in our care tell us that their care workers took time to establish a trusting relationship, and then sought to understand and respond to their physical, psychosocial and relational needs. Conversely, many of those who have a poor experience say that assumptions made by their care workers contributed greatly to their poor experience. These patients tell us that some of the health care staff who cared for them appeared to make assumptions based on outward characteristics such as their ethnicity, age, cultural background or gender, or the presence of a mental health issue, disability, illness or injury (for an analysis of the impact this has on patients please see the implicit bias report from November 2019). They also tell us that some staff assumed patients are more mobile than they are, that they know where things are situated (i.e. blankets, tea and coffee facilities), that they understand medical jargon and are familiar with clinical processes, or that they know nothing about clinical processes and need everything explained in very simple terms. The Fundamentals of Care Framework is therefore designed to remove the need to make assumptions from health care practice by establishing a trusting relationship (covered in the previous report), and then addressing the patient’s fundamental care needs.

This report - the second in our series on the Fundamentals of Care - covers the notion of ‘integrated’ care, or an understanding of how the physical, psychosocial and relational fundamentals of care fit together to enable holistic, person-centred care. Integrating these fundamental needs is necessary for a positive patient experience to occur. For example, an everyday, routine activity that a patient is used to doing independently, such as toileting or bathing, may become challenging or embarrassing as a result of their condition or treatment. In this instance, attending to a patient’s fundamental care needs is not simply a matter of assisting them with their physical need to be safe, toileted and clean. It also requires that we consider their psychosocial needs around keeping them calm, involved, dignified and respected, and that we deal with any embarrassment or discomfort in ways that are empathetic and compassionate. Similarly, helping patients eat also builds relationships and provides an opportunity to assess swallowing, promote socialisation, and ensure proper nutrition. This integration is what fundamental care is all about.

Jenny Parr Chief Nurse and Director of Patient and Whaanau Experience


FUNDAMENTALS OF CARE REPORT PART 2: INTEGRATION OF CARE

1. PHYSICALSAFETYPatients are asking us to wash or sanitise our hands, assist them when they are feeling weak or dizzy and ensure that any spills on the floor are cleaned quickly.

Never once did I receive my medication without proof of self. (Maaori patient)

comfortOur patients appreciate it when we proactively ensure they have adequate relief from pain and/or nausea. Some patients tell us that they were not given enough blankets to keep warm and that staff assume they know where things are kept.

6 AVERAGE

COMFORT RATING:

OUT OF 10

80% OF PATIENTS SAY

STAFF DEFINITELY DID EVERYTHING THEY

COULD TO MANAGE THEIR PAIN

TOILETINGIncontinence is a cause of much anxiety and distress for many patients, more so when they have asked for a bedpan or for help to get to the toilet and have wet the bed while waiting. They ask that we help with their toileting needs when asked, and to remember that these needs are often urgent.

[I would like to ask that] nurses take patients mental state into

consideration when taking care of them and not to make patients feel yuck when helping them with the toilet.

(Pasifika patient)

MOBILITY

CLEANSING + DRESSING

EATING + DRINKING

REST + SLEEPPatients ask that staff are mindful of their noise at night. Many report that their night time rest and sleep is interrupted by slamming doors, loud conversations, phones ringing and laughter.

4

AVERAGE WARD NOISE

RATING:

OUT OF 10

I understand having a laugh with colleagues but it goes on for a while, maybe take it to a smoko room. It’s

important nurses get that time but at the cost of patients sleep time it wasn’t nice.

(Maaori patient)

Patients appreciate it when we check they have what they need to take care of personal needs (e.g. toothbrushes, toothpaste). Those who are being prepared for discharge ask that we make allowances for the time it takes to get dressed.

Patients appreciate it when their meals, and water jugs are placed within easy reach, and they are given the help they need to eat their meals.

20% OF PATIENTS WHO NEEDED HELP TO EAT THEIR MEALS, SAID THAT

THEY DIDN’T GET ANY HELP.

86% OF THESE PATIENTS SAY THE FOOD

THEY WERE GIVEN MET THESE NEEDS

47% OF PATIENTS HAVE DIETARY NEEDS

I had only one hand to eat. Staff placed food in front of me and left. Couldn’t cut meat, butter toast take top off yoghurt etc. (NZ Euro patient)

Our patients are asking us to check what their mobility needs are, and that they have the right aids and assistance to be as mobile as they can.

I wasn’t very mobile (which no one had actually checked) and yet they told me to use the bathroom on the other side

of the ward (NZ Euro patient).

MANAGING MEDICATIONIt’s important to patients that their medication is delivered on schedule, and that we check identity, dosage and medication type before administering the medication.


FUNDAMENTALS OF CARE REPORT PART 2: INTEGRATION OF CARE

2. PSYCHOSOCIAL

EMOTIONAL WELLBEING

EDUCATION + INFORMATION

DIGNITY

RESPECT

Patients expect to be informed about all aspects of their care and treatment, as well as before things happen or when something changes. They also want to be given information they need to make decisions.

24% OF PATIENTS SAID THAT

INFORMATION SUCH AS X-RAYS AND TEST RESULTS WERE NOT

SHARED WITH THEM IN A TIMELY MANNER

All patients want to be treated with dignity. For some, this means being treated with dignity regardless of age, ethnicity, gender, sexual orientation, religion, linguistic or cultural background or the presence of a mental health issue, disability, illness or injury. At CM Health, Maaori patients are less likely to agree they were always treated with dignity and respect when compared with other patients, with 5 out of 10 saying this didn’t always happen during their stay.

Medical terms are hard to understand and it’s kind of confusing to know

what is said ... but if it’s broken down to where I can understand then it’s

really good. (Maaori patient).

19% OF PATIENTS WHO

WANTED THEIR VALUES, BELIEFS,

RELIGIOUS OR CULTURAL NEEDS

RESPECTED SAY THAT THIS DID NOT HAPPEN.

34% OF PATIENTS SAY THEY

WERE NOT GIVEN ENOUGH INFORMATION.

COMMUNICATION

PRIVACY

VALUES + BELIEFSPatients want their values and beliefs to be considered and respected, including views and choices that are guided by religious or cultural practices.

Patients want us to ensure private conversations are held in places where they cannot be overheard. They also ask that we protect their physical privacy by drawing curtains or ensuring bathroom doors are closed properly.

INVOLVED + INFORMED

68% OF PATIENTS SAY THEY HAD ENOUGH INFORMATION TO MAKE INFORMED

CHOICES ABOUT THEIR CARE

60% OF PATIENTS SAY THEY WERE AS

INVOLVED AS THEY WANTED TO BE IN DECISIONS ABOUT THEIR CARE.

Patients report a better experience when they are consulted and given the opportunity to contribute to decisions about their care and treatment.

For our patients, being treated with respect involves healthcare staff asking permission before assisting, treating or examining them, displaying patience and understanding, and being courteous and considerate. They feel disrespected when staff are rude or dismissive, when they feel they haven’t been listened to or have been judged unfairly.

[Nurses] didn’t listen to me when I told them that I had just finished feeding my

baby. One was in my face putting her hands on my breast to force my child to eat and kept telling me that “you have to feed [baby] she’s hungry” even after I said

“she’s already eaten.”(Maaori patient).

6.5

AVERAGE COMMUNICATION

RATING:

OUT OF 10

Patients want us to explain things clearly, using everyday language. They ask that we find out how much they understand about their condition, and tailor our communications towards this.

Even the most resilient patients may experience fear, uncertainty, loneliness or some other form of emotional distress during their care and treatment. Patients appreciate when we respond to their emotional, as well as physical wellbeing.

All the nurses who look after us were really good in calming [my relative]. They talked patiently and calmly and assured

him everything will be alright. They made him smile when his emotions were down.

(Asian respondent)


FUNDAMENTALS OF CARE REPORT PART 2: FUNDAMENTALS OF CARE

3. RELATIONALBEING EMPATHETIC

ACTIVE LISTENING

GOAL SETTING

Patients tell us they feel comfortable with and more connected to healthcare staff who display empathy, which is displayed through active listening, making eye contact or picking up on nonverbal cues.

BEING COMPASSIONATEOur patient experience survey results are filled with patient stories that detail moments of kindness and compassion that, whilst small, are extremely meaningful to patients. They tell us when we display empathy, sensitivity, kindness and warmth they feel genuinely and sincerely cared for.

I was a little overwhelmed to see so many people in the theatre and started

to hyperventilate. I was immediately put at ease by [a staff member] who

came forward to hold my hand ... that totally relaxed me and my fears.

(Maaori patient)

Patients tell us that having mutually agreed, realistic and achievable targets is important for feeling a sense of hope and progress.

I’m a big person and had a particularly nasty-looking wound ... I felt scared and embarrassed at having to show this but the nurses I was dealing with and their

levels of empathy and compassion were stellar. (NZ European patient).

BEING PRESENT + ENGAGED

INVOLVING WHAANAU + CARERS

HELPING PATIENTS COPE

HELPING PATIENTS STAY CALM

Patients cope better when we keep them informed, relieve pain, help with mobility, use humour when appropriate, and are kind and compassionate.

Our patients say that staff help them to stay calm by listening to and answering questions, reassuring them that things are ‘normal’ (even though they don’t feel that way to the patient), checking on them and comforting them when they are struggling.

68% OF PATIENTS

SAY THERE WAS DEFINITELY A

MEMBER OF STAFF THEY COULD TALK TO ABOUT THEIR

WORRIES OR FEARS.

Nurses and doctors knows how scared and sad I was ... they comfort me, and told me that don’t worry I’m gonna be okay. I’m so grateful. (Pasifika patient).

Our patients ask that we give them our full attention when we listen to them. Active listening is about not only listening to what they have to say, but also listening for the intentand feelings of the speaker.

Whaanau and carers bring personal knowledge of the patient's circumstances and preferences that can help the care team understand and consider all of the issues affecting the patient’s condition, care and treatment. Patients who see their whaanau and carers as important members of the care team report a more positive experience when their whaanau and carers are made to feel welcome and given opportunities to speak with staff.

When healthcare staff are present and engaged, patients experience this as “undivided attention”, or attention which is mindful, personal and free of distraction. This kind of attention helps them feel seen, safe and cared for.

Staff gave me kind and good attention even though it was busy. They made me feel like my condition was very

important. (Pasifika patient).

80% OF PATIENTS

SAY CM HEALTH STAFF ALWAYS LISTENED TO

WHAT THEY HAD TO SAY.


Hospital Advisory Committee Meeting Resolution to Exclude the Public

Resolution

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

General subject of items to be considered

Reason for passing this resolution in relation to each item

Ground(s) under Clause 32 for passing this resolution

Public Excluded Minutes of 12 August 2020

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

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

Service Provision 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)]

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

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