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Counties Manukau District Health Board – Hospital Advisory Committee 12 July 2017

HOSPITAL ADVISORY COMMITTEE (HAC) MEETING 12 July 2017

Venue: Room 101, Ko Awatea, Middlemore Hospital, Hospital Road, Otahuhu Time: 1.00pm Committee Members Dr Lyn Murphy – Committee Chair Dr Ashraf Choudhary – CMDHB Board Member Catherine Abel-Pattinson – CMDHB Board Member Dianne Glenn – CMDHB Board Member Mark Darrow – CMDHB Board Member Rabin Rabindran – Deputy Chair

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

APOLOGIES

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

PART 1 – Items to be considered in public meeting AGENDA

1.00pm 1. FLU VACCINATIONS (Room 101) Page No.

1.30pm 2. AGENDA ORDER AND TIMING

3. CONFIRMATION OF MINUTES 1.30pm 1.35pm

3.1 Confirmation of Minutes of the Hospital Advisory Committee Meeting – 31 May 2017 3.2 Action Items Register

6-12 13-14

4. FOR INFORMATION 1.40pm 4.1 Whole of System, Health of Older People (Shankar Sankaran) 15-26

5. PROVIDER ARM PERFORMANCE REPORT 2.15pm

5.1 Executive Summary/Performance Report (Phillip Balmer) 5.2 Balanced Scorecard 5.3 Finance Report (Margaret White) 5.4 Emergency Department, Medicine and Integrated Care 5.5 Surgery, Anaesthesia and Perioperative Services 5.6 Central Clinical Services 5.7 KidzFirst and Women’s Health 5.8 Adult Rehabilitation and Health of Older People 5.9 Mental Health and Addictions 5.10 Facilities 5.11 Middlemore Central

27-37 38-40 41-44 45-51 52-55 56-60 61-67 68-70 71-74 75-76 77-78

Afternoon Tea Break (3.00 - 3.10pm)

6. CORPORATE REPORTS 3.30pm 3.40pm

6.1 Director Patient Care, Chief Nurse and Allied Health Professions Officer (Jenny Parr) 6.2 Human Resources Report (Phillip Balmer)

79-90 91-93

3.50pm 7. RESOLUTION TO EXCLUDE THE PUBLIC................................................................................. 94

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BOARD MEMBER ATTENDANCE SCHEDULE – HAC 2017

Name

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

Dr Ashraf Choudhary

Catherine Abel-Pattinson (Deputy Chair HAC)

Dianne Glenn

Dr Lyn Murphy (Chair HAC)

Mark Darrow

X

Rabin Rabindran

External Appointee TBC - - -



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HAC MEMBERS DISCLOSURE OF INTERESTS

12 July 2017 Member Disclosure of Interest

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

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

and Outcome Research (ISPOR NZ) • Member, New Zealand Association of Clinical

Research (NZACRes) • Senior Lecturer, AUT University School of Inter

professional Health Studies • Member, Public Health Association of New Zealand

Dr Ashraf Choudhary

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

Foundation • Co-Patron, Bharatiya Samaj Charitable Trust

Catherine Abel-Pattinson (HAC Deputy Chair)

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

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

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

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

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

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

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Mark Darrow • Chairman, Primary Industry Training Organisation

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

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

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

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

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

Rabin Rabindran

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

Development Co Ltd • Singapore Chapter Chairman – ASEAN New Zealand

Business Council External Appointee TBC

External Appointee TBC

External Appointee TBC

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HOSPITAL ADVISORY COMMITTEE MEMBERS’ REGISTER OF DISCLOSURE OF SPECIFIC INTERESTS Specific disclosures (to be regarded as having a specific interest in the following transactions) as at 12 July 2017 Director having interest Interest in Particulars of interest Disclosure date Board Action Dr Lyn Murphy

Allied Health Initiative for Education & Development (AHIED)

Senior Lecturer, AUT School of Inter-Professional Health Studies

30 November 2016 8 March 2017

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

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Minutes of Counties Manukau District Health Board

Hospital Advisory Committee Held on Wednesday, 31 May 2017 at 1.30pm

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

PART I – Items considered in Public Meeting

BOARD MEMBERS PRESENT

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

ALSO PRESENT

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

PUBLIC AND MEDIA REPRESENTATIVES PRESENT

There were no public or media representatives present. APOLOGIES

An apology was received and accepted from Mark Darrow.

WELCOME

The Committee Chair welcomed all those present to the meeting.

DISCLOSURE OF INTEREST/SPECIFIC INTERESTS

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

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2. AGENDA ORDER AND TIMING

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

3. COMMITTEE MINUTES

Confirmation of the Minutes of the Hospital Advisory Committee meeting held on 19 April 2017 Resolution (Moved: Lyn Murphy/Seconded: Dianne Glenn) That the minutes of the Hospital Advisory Committee meeting held on 19 April 2017 be approved. Carried

4. FOR INFORMATION

4.1 The Cardiac Network Dr Andrew Kerr, Consultant, Coronary Care and Dr Selwyn Wong, Cardiologist took the Committee through a presentation on the Cardiac Network highlighting the following:

Successes - mortality rates and hospitalisation rates have been progressively falling nationally across all age groups over the last 10 years. The big question is can we go lower. Cardiovascular disease is a whole of system problem. It starts with risk factors that include poverty, obesity, smoking etc and there is long period of opportunity for intervention prior to people having their first stroke or heart attack and ending up in hospital. We need to be able to intervene at every point along the pathway. Opportunities – CM Health’s length of stay for cardiology patients is the highest and well out of keeping with others in the Health Roundtable and reflects a delay in getting access to procedures (wherever) and also reflects morbidity and poverty. Our volumes are much greater than other DHBs h we are doing well in seeing new patients in a timely manner (our clinician volume per clinic is higher than the other DHBs). Angiography is a very important test and makes a difference to outcomes however, we are the only DHB in the country, compared to similar/same size DHBs, that only has one cath lab and this puts us at risk. Christchurch has 3, Waikato has 4, Auckland has 5, Tauranga has 2 and Wellington has 3. There are currently opportunities for improvement: • in primary and secondary prevention medication in primary care • earlier referral from primary care • access to coronary intervention, pacing, ICD in secondary care • access to follow-up care in secondary care and follow-up times need to be improved

Conclusion - we are improving, but we can still go a long way further.

Phillip Balmer confirmed that a preliminary regional capacity demand and options report will be presented to the Service Review Programme Advisory Group on Friday. Once the regional work has been completed, an options paper can be brought back to HAC for discussion. Whilst it was noted that the Board has a responsibility to ensure that our patients get the best possible service, they

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also have a responsibility to ensure that all our resources are prioritised properly and whatever we do, we have to have a plan that will bring about the right result in a timely manner. 5. PROVIDER ARM PERFORMANCE REPORT APRIL 2017 5.1 Executive Summary/Responses to Action Items

Phillip Balmer introduced the report. Matters highlighted or updated included: • Elective surgical discharges sitting at 92% without the last quarter flurry • Seeing improvements in the Faster Cancer Treatment target • Seeing good improvement in our discharges by 11am • Concerns around the 6hr ED target which has dropped to 93% since inception of the

target which reflects that we are seeing pressure in the hospital in terms of acute demand, particularly around acute medicine. There are plans in place to ensure we improve this.

• Hospital projects – as part of the year end process, 65 projects have been identified for closure. We will be working closely with the divisions to ensure benefits or lack of are accurately portrayed as part of the year end process.

Response to Action Item – Acute Psychiatry Mr Peter Watson, Clinical Director, Mental Health took the Committee through the update on the 72 hour assessment period for urgent patients noting that the numbers of first referrals to the Intake & Assessment Team has increased from 60-80% within 24hrs (since January 2016) and the number seen within 48hrs is now nearly 90%. There are always areas for improvement but in general, people are seen quickly and get a good service. Suicide – the coronial process determines when a suicide is a suicide. We now have data coming in real time from the NZ Police about what we suspect is suicide and can use that data and compare across the Auckland-region. We are one of the best performing DHBs in the country in terms of having the lowest rates of suicide. Peter Watson confirmed that suicide rates are not increasing despite what has been reported recently in the media, except to note that every suicide clearly evokes a significant response from families/the community etc. The highest rates were actually recorded in the mid-1990’s. Suicide of people in mental health services occurs but occurs less frequently than deaths from physical health concerns so the problems the service is facing is trying to do better around people’s physical health issues as well as mental health issues by providing integrated healthcare. The Committee agreed they would like to receive a report on how the DHB measures itself against the UK Mental Health Triage Scale model (ie) responses to triage times – how many people that were triaged E we did actually see within 4 weeks etc. Peter Watson confirmed that the service is currently facing some technological issues in measuring some of this data accurately and is currently undertaking an audit to ensure the data is being measured correctly. He agreed to come back with a proposal based on the audit, when completed.

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5.3 Finance Report

Margaret White (acting Chief Financial Officer) summarised this section of the report. Matters highlighted or updated included: The Provider Arm is doing a very good job and will still deliver a forecast result $2m better than budgeted to deliver. By in large this has been managed by careful resource management. We still have a $26m gap to get back to breakeven within 31 calendar days and ELT has made a deliberate decision to prioritise non-core services when looking at that and to ensure we are looking after the front line particularly. The DHB has a very ambitious savings programme for 2017/18.

5.4 Emergency Department, Medicine and Integrated Care Matters highlighted or updated included: • National Bowell Screening Programme – the content required for the MoH programme

business case (to secure funding for the programme) has been submitted to MoH. The DHBs service delivery model has been finalised, a key focus being to ensure the DHB can provide equitable access to its population. At this stage there appears to be a funding shortfall based on the DHBs proposed model and discussions are underway with MoH on how to resolve this. A key risk for the programme is the IT system requirements and MoH have engaged Ernst & Young to assist with this.

5.5 Surgery, Anaesthesia and Perioperative Services

Matters highlighted or updated included: • Acute Demand – there has been a significant increase in acute demand, particularly in

Orthopaedics. The teams have been working very hard in response to that demand by providing additional out of hours surgery and weekends but the Anaesthetic team is short in FTE so are needing to make some adjustments within our workforce so they are able to provide the out of hours access to acute surgery on an ongoing basis. The service is considering options alongside cath lab and alongside regional considerations on how it might address some of the constraints with procedure and theatre capacity.

• Falls Programme the falls programme being rolled out by ACC will be about early detection and prevention. We will always get falls as people come into a setting which is unfamiliar and often when they are unwell they have mobility issues, so it would be unlikely we could eradicate falls altogether, we just need to ensure that we do the best we can to prevent them and try to avoid admissions where possible because it is not a good idea to be admitted if you are at risk of falling.

5.6 Central Clinical Supplies

Matters highlighted or updated included: • Pharmacy – on 20 April, the Associate Minister of Health Hon. Peter Dunne presented

the Health Quality and Safety Commission ‘Open for Leadership Award’ to Sanjoy Nand, Pharmacy Service Manager. Sanjoy and his pharmacy colleagues have implemented

009


initiatives that have improved the quality and safety of medication management for patients. One of those initiatives is SMOOTH – Safer Medication Outcomes on Transfer to Home which aims to reduce errors and harm from medicines to patients at the discharge interface and thereby reducing readmissions. This project is now embedded as business as usual. The Committee agreed to send a letter of congratulations to Sanjoy and his team.

• Histology - the Committee toured the Histology Lab prior to the meeting commencing

today and agreed that the lab seemed far too over-crowded and that this was not acceptable and put the staff at risk of making errors. Phillip Balmer advised that a regional options analysis review of Histology is underway and would expect that a business case should be finalised for Board approval by the end of this quarter. He agreed to provide an update on the regional review at the next HAC meeting (12 July).

5.7 Women’s Health and Kidz First

Kidz First ED admissions – the number of admissions is lower than the previous year and acknowledge that most of this is to do with respiratory illness but have also seen a drop in ASH rates for Maaori. Did the Under 13 Free make a difference and will it happen again this winter are questions currently being looked into. MCIS – It was noted that the DHB upgraded to v13 on 10 May 2017 however, the system is still far from perfect. This upgrade addressed some of the clinical risk issues but did not mitigate all the areas identified for further development and changes. The national MCIS Governance Group (consisting of sector and MoH representatives) met on 26 May and put a challenge back to the Ministry that in its present form it is not a satisfactory product and a decision needs to be made in terms of direction from the Ministry. Phillip Balmer to provide further clarification at the next meeting (12 July).

5.8 Adult Rehabilitation and Health of Older People This report was taken as read.

5.9 Mental Health and Addictions This report was taken as read.

5.10 Facilities and Asset Management This report was taken as read.

5.11 Middlemore Central Influenza vaccinations – sitting at 58% as of today, a lot more work needs to be undertaken. The DHB normally reaches around the 67-70% rate. The Committee agreed they should lead by example and have an influenza vaccination at the next HAC meeting (12 July). Phillip Balmer to co-ordinate this.

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6. CORPORATE REPORTS 6.1 Director of Patient Care, Chief Nurse and Allied Health Professions Officer

Jenny Parr introduced the report. Matters highlighted or updated included: Volunteers/Shuttle Service – the shuttle service was temporarily put on hold in March 2017 while the organisation ensured the volunteer drivers completed police, health and safety and licencing checks, in line with recent changes to legislative requirements. Jenny Parr reiterated that the explanation/apology that went to the Board had several opportunities for things to be done better. The Manager of the service has moved into another role with Jo Rankin taking over. It is Volunteer Week next week and Jo will be attending to demonstrate the value that we feel around the work the volunteers undertake. The roster for the shuttle service is being reviewed and is anticipated that the service will be back on the road by 19 June.

6.2 Human Resources The report was taken as read. 6.2 Inpatient Experience Report No. 2

The April report focussed on Communication. If we get communication right then patients are far more likely to tell us we are doing a good job overall. Research shows that good communication leads to greater diagnostic accuracy, more active engagement of patients in their care and higher patient satisfaction with care.

7. RESOLUTION TO EXCLUDE THE PUBLIC

Resolution (Moved: Dianne Glenn/Seconded: Catherine Abel-Pattinson) That in accordance with the provisions of Schedule 3, Clause 32 and Sections 6, 7 and 9 of the NZ Public Health and Disability Act 2000: The public now be excluded from the meeting for consideration of the following items, for the reasons and grounds set out below:

General Subject of items to be considered

Reason for passing this resolution in relation to each item

Ground(s) under Clause 32 for passing this resolution

2.1 Confidential Minutes of 19 April 2017

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

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

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3.1 Food Service

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 Board to carry out, without prejudice or disadvantage, commercial activities. [Official Information Act 1982 S9(2)(i)]

3.2 Patient Experience and Safety Report

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

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

Carried

The open session of the meeting concluded at 4.10pm

SIGNED AS A CORRECT RECORD OF THE COUNTIES MANUKAU DISTRICT HEALTH BOARD HOPSITAL ADVISORY COMMITTEE MEETING OF 31 MAY 2017. Lyn Murphy, Committee Chair

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


Hospital Advisory Committee Meeting – Public Action Items Register – 12 July 2017

DATE ITEM ACTION DUE DATE RESPONSIBILITY COMMENTS/UPDATES COMPLETE

Standing Items

8.3.17 2.4 Summary of Annual Leave Cash-Ups for Hospital Services Directorate – provide a quarterly report showing, for those staff that have had annual leave paid out, their current leave balance, leave accrual and leave taken. This report will not specifically identify particular individuals due to privacy issues.

12 July Margaret White/ Phillip Balmer

Refer Item 6.2 on today’s agenda.

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

23 August Jenny Parr

31.5.17 6.11 Medicine - Bowel Screening Programme regular update via the Medicine report each meeting.

12 July Brad Healey Refer Item 5.4 on today’s agenda.

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

12 July Jenny Parr Refer Item 6.1 on today’s agenda.

31.5.17 6.1 Hospital Services 2016/17 Project Initiatives – full report on initiatives including specific bed day savings where applicable and benefits realisations to be reported back on a quarterly basis (with updates in the Executive Summary at alternative HAC meetings).

12 July Phillip Balmer Refer Item 5.1 on today’s agenda.

19.4.17 5.1 Director’s Report - SLM quarterly report (with updates in the Executive Summary at alternative HAC meetings)

12 July Phillip Balmer Refer Item 5.1 on today’s agenda.

19.4.17 7.6 Director of Midwifery – report back on what the next

steps will be on the primary birthing units (location & number) after the MQSP report is signed off by the Ministry. This plan is not expected to be finalised until June 2017 so a copy will be provided to HAC on 12 July (tbc).

12 July Nettie Knetsch This item is to be removed.

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


DATE ITEM ACTION DUE DATE RESPONSIBILITY COMMENTS/UPDATES COMPLETE

30.11.2016 6.6 EC, Medicine & Integrated Care – report back with an update on the issues associated with why it is so difficult for Maaori & Pacific women to get their breast screening done - September result show Maaori (182 v target of 269), Pacific (298 v target of 370).

12 July Phillip Balmer/ Brad Healey


31.5.2017 5.1 Acute Psychiatry – the Committee agreed they would like a regular report on how the DHB measures itself against the UK Mental Health Triage Scale model (ie) responses to triage times (how many people that were triaged E we did actually see within 4 weeks). The service is currently facing some technological issues in measuring some of this data accurately and is undertaking an audit to ensure the data is being measured correctly. Tess to come back with a proposal based on the audit, when completed.

Date TBC Phillip Balmer/ Tess Ahern


31.5.2017 5.6 Central Clinical Supplies/Histology – provide an update on the regional options analysis review currently underway.

12 July Phillip Balmer/ Ian Dodson


31.5.2017 5.7 Women’s Health & Kidz First/MCIS – provide an update on the status of MCIS following the meeting on 26 May.

12 July Phillip Balmer/ Nettie Knetsch


31.5.2017 5.11 Middlemore Central – the Committee agreed they would like to lead by example and have an influenza vaccination at the next HAC meeting.

12 July Phillip Balmer Being conducted at 1pm today.

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Counties Manukau Health Health of Older People Services

Dr. Shankar Sankaran, Clinical Leader, Whole of Systems

Health of Older People

July 2017 015

Presentation Outline

• Background on HOP Service • Falls & Fragility Fracture Prevention in Older People - Hip Fracture Care (Orthogeriatric Service) - Fracture Liaison Services - Community Falls prevention • Community Geriatric Services • Acute Care for the Elderly • Front door support (HOPE Service – starting Sept 17)

016

v

Improving falls and fracture service outcomes for older people Whole of Systems Approach

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Falls and fracture care and prevention A road map for a systematic approach

Hip fracture patients

Objective 1: Improve outcomes and improve efficiency of care after hip fractures

Non-hip fragility fracture patients

Objective 2: Respond to the first fracture, prevent the second – through Fracture Liaison

Services in acute and primary care

Individuals at high risk of 1st fragility fracture or other

injurious falls

Objective 3: Early intervention to restore independence – through falls care pathway

linking acute and urgent care services to secondary falls prevention

Older people Objective 4: Prevent frailty, preserve bone

health, reduce accidents – through preserving physical activity, healthy lifestyles and reducing

environmental hazards

Stepwise implementation -

based on size of impact

1. DH Prevention Package for Older People

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Hip Fracture Care Standards

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Fracture Liaison Services What they do reliably that other service configurations don’t

• Identification: – All men and women over 50 years of age who present with fragility

fractures will be assessed for risk factors for osteoporosis and future fractures

• Investigation – As per relevant local/regional/national guidelines, those at risk will

undergo BMD testing and fracture risk assessment

• Initiation – Where appropriate, osteoporosis treatment will be initiated and

referral to falls prevention services

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CMH Community Falls Prevention Programme

• Phase 1 – Primary care led Population based screening for over 75 year olds and over 65 year old Maori/Pacific with fall related ACC claim within previous 1 yr and referrals to Falls Programmes

• Phase 2 – Referrals from Secondary care (FLS/ED/Acute and A T &R) and St. Johns to Falls programmes

• Phase 3 – Referrals from Community (Pharmacies/Hair dressers/Churches)

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Appendix I - Falls pathway ACC and CM Health Community Falls Prevention Programme collaborative

Age 75 years and older and enrolled with a CM Health general practice

Age Residential Care Client Dementia Not eligible for programme

Community dwelling Eligible

3 x screening questions administered via telephone (anyone can administer): 1. Have you slipped, tripped or fallen in the last year? 2. Can you get out of a chair without using your hands? 3. Are there some activities you’ve stopped doing because you are afraid you might lose

your balance? Do you worry about falling?

No to Qs 1 and 3; Yes to Q2 – No further follow up Recall for 12 months

Yes to Qs 1 or 3 or No to Q2 Make a time for the patient to come in and/or check when they are next due in (within 3 months or earlier if clinically indicated)

Administer 2 timed functional assessments: 1. Timed Up and Go (TUG) Test AND 2. Tandem stand

Timed Up and Go (TUG) Test ≥12 seconds AND Inability to hold tandem stand for 10 seconds

And meets the following: • Cognitively intact • Not receiving a personal care

package • Not utilising a walker

internal/external

And meets the following: • Cognitively intact or mild

cognitive impairment • Receiving a personal care

package • Utilising a walker

internal/external

Consider multifactorial falls risk assessment as per HQSC

First best responder will do home visit and complete assessment In addition to strength and balance programme may be referral to other specialists as required

Timed Up and Go (TUG) Test ≤12 seconds OR Ability to hold tandem stand for 10 seconds

Consider multifactorial falls risk assessment as per HQSC

Maori and Pacific Island people age 65-74 years with an ACC approved fall related claim in previous 12 months

Electronic referral to ACC Lead Provider

Electronic referral to Community Central

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Community Geriatric Services

• Specialist support to Aged Residential care and primary health care

• Launched in 2008 and in alignment with the MOH’s ‘Better sooner and more convenient primary care’

• Medication Review support, Hotline support and Advanced Nursing support

• Reduction in inappropriate residential care presentations to ED

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Acute Care for the Elderly

• Provide more coordinated care to acutely unwell, non-specialised medical patients over 85 years old

• Involve earlier multidisciplinary team (MDT) interventions to reduce deterioration during the acute phase.

• Enable early discharge planning. • Improve linkages to inpatient rehab services in

AT&R. • Coordinate patient’s ongoing care with community

services. 024

Front Door Support (HOPE Service)

• Proactive HOP specialist medical/nursing support to ED front door

• Geriatrician/CNS review for frail older patients (with set criteria) in ED short stay unit

• Proactive support to APAC/POAC service • Appropriate discharge of older patients to Community Reablement POAC AT&R Inpatient acute services Community Falls Prevention Programmes

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Counties Manukau District Health Board Hospital Advisory Committee

Hospital Services Report

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

ARHOP Adult Rehabilitation and Health of Older People DHB District Health Board ED Emergency Department FY Financial Year GP General Practitioner/General Practice KPI Key Performance Indicator LOS Length of Stay MMH Middlemore Hospital MSC Manukau SuperClinic PHO Primary Health Organisation SLM System Level Measures Overview

In recent years, CM Health has experienced relatively stable numbers of inpatient events, although the number of overnight bed days has slowly crept up. During this time we have also seen a reduction in demand growth at our front door, and have consistently achieved the national six hour ED target. We have implemented a range of initiative across the system to both reduce demand at our ED and manage capacity across the hospital system; this has resulted in a more vertically integrated care process for a range of our services, and a more focussed approach to coordinated community intervention and response to avoid admissions and reduce the likelihood of readmissions occurring. While we have made good progress, the steady increase in patient acuity and the recent step change in ED demand, has challenged our system more so than ever before. We now have an unprecedented number of patients presenting to hospital, and our ability to match demand for beds with our existing capacity is being tested on an almost daily basis. The hospital-wide balanced scorecard, finance, and human resources reports included provide a consolidated view of organisational performance, and this month we have also provided a more detailed report on the performance of our 2016/17 initiatives programme.

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Summary of Financial Position

The Provider Arm has delivered a favourable financial result of $382k for the month of May. We are also favourable $320k for the year to date. We remain focussed on maximising revenue opportunities and improving efficiencies as the financial year draws to a close. National Health Targets

Again in May we did not meet the six hour ED target, with a result of 93% (against a target of 95%) reported for the month. As a result, CM Health will not meet the target for quarter four of the current financial year. Higher patient volumes across the system have impeded patient flow throughout the hospital, which in turn has meant our ED has been unable to process patients within the target timeframe. A range of initiatives are underway to address underlying system challenges and manage demand. We also did not meet the Faster Cancer Treatment target in May, achieving 81% of the 85% target. As of 1 July 2017, the target will increase from 85% to 90%; however, the definition at this time will also change. Currently, breaches can be attributed to patient choice, clinical consideration, or capacity constraints. When the new target takes effect, only those relating to capacity constraints will be counted as breaches. Accordingly we expect our performance against the target to improve, despite the increase to 90%. Delivery of the elective surgery target has been sustained, with a confirmed result of 104.2% for April, and an indicative result of 104.8% for May. System Level Measures

One of the workstreams associated with the SLMs is to reduce acute demand both in terms of ED presentations and acute bed days. System level initiatives are being developed and implemented in conjunction with primary care to achieve reductions in acute demand. The workplans are both local and regional. Workshops are being held with representatives from PHOs, GPs, DHBs, and others to engage clinical teams with the respective workplans and to develop monitoring metrics. A number of initiatives are already in place and starting to realise some improvements. Notable areas include the increase in discharges by 11am and referrals to reablement. Performance against the initiatives underway is provided below.

Target Full Year YTD YTD%2.3% 112,077 110,509 0.7%

15.0% 31,528 31,113 2.1%

15.0% 4,106 4,032 6.6%

15.0% 6,534 6,436 0.8%

20.0% 9,185 9,010 3.1%

25% NA 17,829 29.3%

20.0% 524 520 48.7%

Legend of Indicator Legent of SparklineLess than halfway to Target Halfway to Target Achieved Target

Whole System Measures

As of 26-Jun-2017

KPI Target Current

YTD By MonthED Presentation 112,348

ED Admit to Inpatient Ward 35,843

Inpatient LOS > 10 Days 5,056

Inpatient Readmission Within 28 Days 7,508

Inpatient Discharge at Sunday 7,275

Inpatient Discharge by 11AM (MMH) 20,884

Referrals to Reablement 644

Current Financial Year Previous Financial Year

028


Capacity and Demand

Emergency Department Our targeted improvement work has meant we have seen a net average increase in ED demand of only 1.9% since 2015. Despite the reorganisation and alignment of services to improve care across the continuum, we continue to be challenged by an increase in acute demand for adults, both in terms of volume and complexity.

This acute demand has become more evident since the cold of winter has set in, with a dramatic spike in presentations to both our adult and paediatric EDs. Combined, our adult and paediatric ED presentations during June have increased to record levels, and much earlier than in previous years. During June we have had over 350 patients presenting each day, with presentations reaching a peak of 393 on 26 June. Over a third of patients presenting have required admission to hospital.

As shown below, our adult ED demand pattern during 2017 has reached peak levels of previous winters much earlier in the year. Peak levels in May/June are higher than the peak levels seen in August 2015.

Projected

Area Specific measure FY2015 FY2016 FY2017* FY2018

Emergency Department Presentations - Adults 83,609 88,610 89,291 92,304 3.37%

Presentations - Paeds 25,845 26,105 23,905 23,018 -3.71%

Presentations - Total 109,454 114,715 113,196 115,322 1.90%

% Patients referred to inpatient services 63.40% 64.80% 65.20% 66.12% 1.41%

% Patients discharged from ED* 37.00% 37.00% 39.00% 40.05% 2.70%

* Number of patients discharged from ED as a physical space

Actual Avg Annual Growth

029


Our paediatric ED presentations, which have been decreasing in recent years, have also spiked during June. Again, this is much earlier than expected based on the patterns of previous years.

Hospital Capacity Alongside the peak in ED demand, we are seeing an increase in hospital bed occupancy. As the hospital fills our ability to effectively move patients throughout the system reduces, resulting in delays which are reflected in our ED six hour target performance. The graph below shows that the combined bed day occupancy (for Medical, Surgical, and ARHOP services) during May was the highest CM Health has ever experienced. (N.B. June –December 2017 are extrapolated based on Cap-Plan demand projections.

NB: June to December 2017 reflects projected occupancy only During the month of May we experienced five hospital full days (known as Dot Days), and a further seven Dot Days during June. Dot days do not mean we have no beds to admit patients into but rather reflect an algorithm measuring acute demand for services as follows:

• Occupancy in Medical and Surgical adult inpatient wards, and Ward 31 (Stroke and Rehabilitation), is ≥100%; there are no available adult beds, there are ≥25 acute admission bed requests, Medical Assessment Unit occupancy is ≥75%, and other suitable beds (including C-Pod, Ward 2 additional beds, or other non-resourced areas) have been opened and have patients.

• Consideration is also given to high theatre minutes and the number of over census patients on wards.

02000400060008000

1000012000140001600018000

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

Combined Medical, Surgical, ARHOP Occupancy by Month, Year

2014 2015 2016 2017

030


Our Response In order to improve flow throughout the hospital, and subsequently raise our performance against the ED target, we are first and foremost focussing on creating additional much needed capacity in a fast, safe, and sustainable way. Specifically we have:

• Expanded our existing bed capacity earlier in the year through the opening of the integrated stroke unit in Ward 31.

• Opened and resourced 34 additional (existing un-resourced) beds to match the winter demand we are experiencing; normally this action would take place further into the winter season.

• Ensured our MSC bed and theatre capacity has been fully utilised for elective surgery, off-setting demand at Middlemore Hospital and ensuring the availability of acute theatre capacity (which reduces lag time to surgery and associated preoperative length of stay).

• Revised our policy of same sex occupancy of shared rooms to align with the region and provide us with more flexibility.

• Continued our focus on increasing the number of patients discharged by 11am to 30%, and extended the operating hours of the Discharge Lounge to include Saturdays. Additionally, we have reorganised our support services (cleaning, orderlies, transit nurses, health care assistants, patient flow controllers) to ensure beds are available as soon as possible after discharge.

Activity underway to improve the management of demand at the front door includes:

• A redesign of our trigger tool and related response cascade to ensure we are able to respond effectively to patient surges.

• Increased the number of senior and resident medical officers in the ED. • Expanded the focus of daily multidisciplinary meetings to coordinate the combined hospital

and community response to the demand. • Improved the use of short stay units for appropriate fast-track patients. • Coordinated a targeted communications campaign across our community to ensure the

public is seeking care from the most appropriate provider for their illness. In addition to the activity highlighted above, we are also exploring how the additional capacity that will be created by Ko Awatea II can be utilised to increase clinical capacity elsewhere on our Middlemore campus. We are also engaging closely with Waitemata and Auckland DHBs to understand demand and capacity constraints from a regional perspective, and to work collaboratively in finding short and long term solutions for our wider Auckland population. Flu Fighters Finally, I would like to commend the Committee for their request to receive flu vaccinations at the July meeting. Influenza is a serious illness and is a key contributor to our ED and system-wide demand over winter. The graph below shows the sentinel flu rates for the Auckland region this year, and provides a valuable reminder of the importance of being vaccinated. Colder winters and poor heating in South Auckland expose our community to a significant risk of sickness and death.

The CM Health Flu Fighter campaign has been running for a number of weeks now, and encourages staff to receive a vaccination both for their own health and the health of their patients. It is pleasing to report that 65% of CM Health workforce have received their flu vaccination.

031

Counties Manukau District Health Board – Hospital Advisory Committee Agenda 12 July 2017

Initiatives Programme Glossary

ACC Accident Compensation Corporation DHS Director Hospital Services/Hospital Services Directorate STEEEP Safe, Timely, Efficient, Effective, Equity, Patient-Centred YTD Year to Date Overview

Each year, in order to remain a financially sustainable operation that continues to provide high-quality and effective healthcare, the Hospital Services Directorate sets an ambitious work programme consisting of a number of service-led transformation, improvement, and revenue initiatives. The information to follow looks at the management and delivery of our 2016/17 initiatives, and provides an overview of our approach to 2017/18. 2016/17 Review

Summary of programme and approach At the beginning of the financial year our services had identified 178 initiatives to deliver throughout the year in addition to their business-as-usual activity. These initiatives were stratified into one of four key outcome categories:

• Transformation - Initiatives which will enable significant business transformation, and change how we provide services to patients and carry out our operations.

• Service Improvement - Initiatives which will enable us to put in place new processes and procedures within services, or reconfigure how we operate, to improve outcomes.

• Business as Usual - Improving existing processes and practice to improve quality, patient safety, experience of care, and to use our resources efficiently.

• Revenue - Opportunities to increase revenue or deliver savings through reducing costs or avoiding budgeted costs.

Category Number Examples

Transformation 31 Healthy Together Technology Projects, Manukau Wellness Park

Service Improvement 73 Production Planning initiatives, Navigation

Business As Usual 41 Optimising Patient Flow, Reducing Harm, Improve Data Quality

Revenue 33 ACC Rehab Revenue, National Procurement, Bureau Reduction In addition to aligning initiatives to key outcome categories, initiatives were also aligned to STEEEP drivers and focus areas (Community Health, Reducing Variation, Revenue, Well Coordinated Care). By applying a number of different lenses to our work programme, we were able to identify and articulate how our initiatives contributed to wider organisational priorities and our strategic direction. All of our initiatives had defined benefits (both financial and non-financial), which were actively monitored and managed throughout the year. A standardised process for capturing and reporting progress was utilised, supported by the Strategic Programme Management Office and the online project management tool Daptiv. The ongoing management and review of our programme enabled us to continually rationalise and combine initiatives throughout the year, which over time reduced the number of discrete initiatives within the programme, and achieved additional efficiencies in the delivery of unified projects.

032


Progress throughout the year It was pleasing to see a number of initiatives progress through delivery phases throughout the year. The table below summarises the number of projects within each phase at the beginning of each quarter, and the current status at the time of preparing this report.

Number of initiatives in phase

Phase Start of Q1 Start of Q2 Start of Q3 Start of Q4 YTD (May)

Initiation 77 46 19 16 16

Planning 49 58 38 34 31

Execution 43 51 69 58 52

Close Out 0 1 12 14 23

Operations 8 8 12 22 23

On hold 0 2 6 12 10

Total 177 166 156 156 155

The graph below depicts the current status of projects within each division.

033


Financial Benefits As part of the 2016/17 budget process, initiatives within the workplan with associated financial benefits were identified to enable savings across the organisation. The savings goal for 2016/17 was established at $16.45M. These savings were identified from initiatives driven by specific divisions and services, strategic programmes of work (e.g. Health Together Technology), and regional and national programmes (e.g. healthAlliance FPSC National Procurement). Of the initiatives identified for the 2016/17 year, 42 were identified as contributing towards the savings plan for the year. Savings plans were aligned to budgets for each division, and where there was a gap between target savings and the financial benefits associated with planned initiatives, a stretch target was assigned. Baseline forecasts for each initiative were established and uploaded to Daptiv, with benefit realisation monitored regularly as part of overall programme delivery. The year to date savings from these planned initiatives (reporting for the period to end of April 2017) is $10.46M against the forecasted target of $12.06M, against a planned target of $16.45M for the year.

Division Budgeted Forecast - $K

Current Initiative

Benefits - $K

+ Stretch Target - $K

= Total Current

Forecast - $K

YTD Planned Target -$K

(Apportioned Forecast / Excl

Stretch)

YTD Actual Benefit -$K

Acute 247.59 150.57 97.02 247.59 88.09 3.00 ARHOP 2,347.97 2,232.63 115.34 2,347.97 1897.43 1591.70 Central Clinical Services

2,429.08 1,596.92 832.16 2,429.08 2086.79 345.67

DHS / Cross Divisional 4,172.50 4,114.32 58.18 4,172.50 3292.95 5106.43

Facilities 29.54 25.11 4.43 29.54 24.15 14.70 Kidz First 114.63 106.87 7.76 114.63 95.44 222.23 Emergency, Medicine, Integration

1,125.08 862.32 262.76 1,125.08 633.27 365.84

Mental Health 396.76 234.11 162.65 396.76 136.93 0.00 MMC 200.85 187.37 13.48 200.85 150.60 117.64 Surgical 4,402.78 3,838.85 563.93 4,402.78 3188.02 2047.25 Women’s Health 979.54 973.27 6.27 979.54 467.78 652.06

Overall 16,446.32 14,322.34 2,123.98 16,446.32 12,061.44 10,466.52

Overall, our Revenue focus area performed the best and exceeded baseline targets. The other focus areas did not meet their baseline targets, reflecting challenges in delivering savings from areas requiring a greater degree of sustainable change to enable benefits. Across the course of the year, our stretch goal grew from $1.79M to $2.12M. This meant our divisions had to make additional unplanned savings to meet their budget. YTD performance by division is depicted in the following graph.

034


The majority of divisions have performed well, delivering savings close to target. Divisions with lower than expected savings were:

• Central Clinical Services - This is largely due to the National Food Services Project failing to deliver any financial benefits, Radiology reduction in additional reads not delivering benefits, and the impact of the delayed opening of the Retail Pharmacy.

• Surgery, Anaesthesia and Perioperative Services - A notable impact was the cancellation of the Chronic Pain Service, planned to transition to Primary Health and Community Services.

In addition, a number of strategic initiatives did not perform as well as expected, which impacted a number of our divisions. Examples include lower than anticipated savings resulting from the healthAlliance Procurement initiative, and the delivery of Healthy Together Technology taking longer than originally planned (with most benefits now anticipated in the 2017/18 financial year). These have been offset by a number of initiatives which have significantly exceeded their forecasted target (examples include ACC revenue initiatives, and closure of non-essential ward space over Christmas). Linking 2016/17 to 2017/18 As part of ongoing management process, 2016/17 initiatives have been reviewed to determine whether they should be carried forward to the next financial year, and if so, whether they are to stay in their current form or require revision. As a result of this review, we plan to incorporate 107 of our current initiatives into our portfolio for next year.

State moving into 2017/18 Number of initiatives Percentage of portfolio

Completed 46 27%

Continue in current form 79 46%

Continue in revised form 28 16%

No further activity 19 11%

035


2017/18 and beyond

Planning for the 2017/18 project portfolio, including the development of an associated savings plan, is well progressed. We have refined our approach for the coming financial year; three clear portfolios of work have been identified, with a number of outcome areas contributing to each. This will enable us to clearly align our efforts to CM Health’s key strategic investment areas, better support the delivery of Healthy Together 2020, and work more collaboratively and effectively with our regional DHB colleagues. 2017/18 Portfolio As part of delivering to our Health Together 2020 strategy, three strategic portfolios of work have been established, and will represent the strategic investment areas for CM Health.

1. Excellent Care 2. Infrastructure and Assets 3. Service Improvement

Nine key outcome areas have also been identified which all project work will be aligned to; these areas cover improvements associated with System Level Measures, as well as the provision of safe and high-quality healthcare, improving systems and processes through technology, regional design for services, and enhancing revenue.

Savings plan Savings initiatives for 2017/18 have been identified across all areas of the organisation, with a summary of forecasted savings by portfolio and outcome area provided in the table below.

Portfolio/Outcome area Total forecast financial benefit

Excellent Care

Planned Proactive Care $3.231

Improving Hospital Flow/Reducing Acute Admissions $4.824

Well-Coordinated Care $4.833

Safe, High Quality Healthcare $0.000

036


Regional Design $0.000

Redesign $0.000

Infrastructure and Assets

Technology Enablers $1.000M

Service Improvement

Reducing Variation $2.719M

Revenue $5.407M

Grand Total $22.014M

Reporting to the Hospital Advisory Committee Delivery of our 2017/18 initiatives programme will continue to be reported to the Committee, as we have for the 2016/17 year. Ongoing feedback from the Committee on what information is provided, and how the information is presented, is sought. CM Health is currently implementing organisational maturity plans in the areas of change, project, programme, and portfolio management. As this work continues we expect to provide an increasingly refined level of reporting.

037


Balanced Scorecard

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

Trend by monthFY16-17 May-17 Target Var Actual Target Var

Emergency Department - 6 hour Length of Stay target 93% 95% -2% 95% 95% 0%FCT % of high suspicion first cancer treatment within 62 days (indicative result) 81% 85% -4% 77% 85% -8%Elective surgery discharges 1,446 1,244 16.2% 13,908 12,413 12.0%


Total Caseweight 7,526 7,640 -1.5% 80,208 81,483 -1.6%Acute Caseweight 5,937 5,908 0.5% 63,555 64,203 -1.0%Elective Caseweight 1,589 1,732 -8.3% 16,653 17,280 -3.6%Total Discharges - performace compared to prior year. 9,243 9,238 0.1% 95,143 95,965 -0.9%Outpatient First Specialist Assessment Volumes 5,163 4,877 5.9% 50,497 51,366 -1.7%Outpatient Follow Up Volumes 12,450 12,039 3.4% 114,518 124,199 -7.8%Virtual First Specialist Assessments (GP consult and nonpatient appointments) 376 329 14.3% 4,120 3,475 18.6%Budgeted FTEs 6,210 6,037 -2.9% 6,003 6,038 0.6%Operating Costs ($000) $25,197 $21,614 -16.6% $242,343 $235,035 -3.1%Personnel Costs ($000) $50,085 $50,337 0.5% $525,151 $533,708 1.6%Financial Result Total ($000) -$3,320 -$3,702 10.3% -$16,816 -$17,136 1.9%Reduce clinical outsourcing ($000) $2,377 $2,395 0.7% $25,815 $25,496 -1.3%

Trend by monthFY16-17 Apr-17 Target Var Actual Target Var

Excess Annual Leave dollars ($000) - estimated cost for excess $3,700 $1,847 -$1,853 $3,525 $1,239 -$2,286Adult Rehabilitation and Health of Older People $57 $65 $8 $71 $81 $10Medicine, Acute Care and Clinical Support $460 $958 $498 $508 $358 -$150Surgical and Ambulatory Care $1,433 $475 -$958 $1,427 $466 -$961Mental Health $313 $176 -$137 $302 $166 -$136Women's Health and Kidz First $656 $174 -$482 $710 $168 -$542

% Staff Annual Leave >2 years 11.4% 5.0% -6.4% 11.6% 5.0% -6.6%Adult Rehabilitation and Health of Older People 4.4% 5.0% 0.6% 4.4% 5.0% 0.6%Medicine, Acute Care and Clinical Support 2.4% 5.0% 2.6% 7.1% 5.0% -2.1%Surgical and Ambulatory Care 15.1% 5.0% -10.1% 15.3% 5.0% -10.3%Mental Health 8.9% 5.0% -3.9% 9.1% 5.0% -4.1%Women's Health and Kidz First 18.9% 5.0% -13.9% 21.1% 5.0% -16.1%

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

Nat

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Year to date

Ensu

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Fin

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Year to date

Average last 12 months

038



% Staff Turnover (YTD no. voluntary turnovers by average headcount) 11.0% 10.0% -1.0% 10.8% 10.0% -0.8%% Sick Leave 3.6% 2.8% -0.8% 3.1% 2.8% -0.3%Workplace Injury per 1,000,000 hours 3.0 10.5 7.5 10.9 10.5 -0.4

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

Maaori 7% 16% -10% 7% 16% -9%Pacific 13% 23% -10% 12% 23% -11%Asian 30% 23% 7% 29% 23% 6%NZ European / non-specified/ other 49% 38% 12% 52% 38% 14%


% e-medication reconciliation - high risk patients within 48hrs (May-17) 74% 80% -6% 68% 80% -12%% Serious Pressure Injuries rate / 100 Patients 0.4% 3.5% 3.1% 0.2% 3.5% 3.3%Falls causing major harm rate / 1,000 bed days 0.11 0.00 0.11 0.06 0.00 -0.06Adverse Events: % of admissions affected by ≥4 triggers 1.1% N/A N/A 1.3% N/A N/ACentral Line Associated Bacteraemia (CLAB) rate / 1,000 bed days in ICU 0.00 0.00 0.00 0.90 0.00 -0.90Rate of S. aureus bacteraemia rate / 1,000 bed days 0.07 0.00 -0.07 0.07 0.00 -0.07

Q1 FY17 Target Var Actual Target Var% 75+ years assessed for the risk of falling # 93% 90% 3.0% N/A N/A N/A% 75+ years assessed for falls risk with falls intervention plans # 96% N/A N/A N/A N/A N/A


% Magnetic Resonance Image (MRI) scans completed within 6 weeks from referral 78% 85% -7% 79% 85% -6%% Computerised Tomography (CT) scans completed within 6 weeks from referral 96% 95% 1% 97% 95% 2%% urgent diagnostic colonoscopy within 14 days 96% 85% 11% 96% 85% 11%% diagnostic colonoscopy patients within 42 days 58% 70% -12% 66% 70% -4%% surveillance colonoscopy patients within 84 days 93% 70% 23% 81% 70% 11%% cardiac STEMI-PCI (angiography) <120mins - Northern Region 100% 80% 20% 86% 80% 6%% Coronary Angiography within 90days (1mth arrears) 85% 95% -10% 94% 95% -1%ESPI 2: No. patients waiting >120 days for FSA - Elective ∆ 0.0 0.0 0.0 0.0 0.0 0.0ESPI 5: No. patients waiting >120 days treatment - Elective ∆ 3.0 0.0 -3.0 3.0 0.0 -3.0Radiology - Inpatient radiology completion times <24hrs 93% 95% -2% 94% 95% -1%Radiology- Emergency Care radiology completion times <2 hrs 95% 95% 0% 93% 95% -2%FCT - % confirmed diagnosis first cancer treatment within 31 days 89% 85% 4% 88% 85% 3%% Radiology results reported within 24 hours 49% 75% -26% 58% 75% -17%

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(con

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Workforce DiversityMonth to date

Average last 12 months

Year

Tim

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Year to date

Firs

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arm

(Saf

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Year to date

Quarterly reporting

039



Average Length of Stay - Acute Inpatient 2.9 3.0 0.1 2.7 3.0 0.3Average Length of Stay - Acute Arranged/ Elective 1.6 1.4 -0.2 1.7 1.4 -0.4Middlemore Hospital % patients to discharge lounge or home by 1100hrs 22% 30% -9% 18% 30% -12%Acute Readmissions within 7 days - Total 2.4% 2.7% 0.2% 2.6% 2.9% 0.3%Acute Readmissions within 28 days - Total (1 month in arrear) 6.7% 6.9% 0.2% 6.8% 7.1% 0.3%Acute Readmissions within 28 days - 75+ years (1 month in arrear) 13% 13% 0.4% 11% 12% 0.9%Emergency Department Presentations - 75+ year olds 1,036 807 -229 1,002 807 -195% clinical summaries (meddocs) authorised <7 days of creation 72% 95% -23% 72% 95% -23%% of patient outliers - not on home ward <5% 2.9% 5.0% 2.1% 3.8% 5.4% 1.6%

% DHB Mental Health Services - children/ youth (0-19years) seen by 3 weeks for non-urgent 75% 80% -5% N/A N/A N/A

Mental Health access rate - clients seen in last 12 months as % of population (0-19yrs) 3.8% 3.2% 0.7% N/A N/A N/AMental Health access rate - clients seen in last 12 months as % of population (20-64yrs) 3.8% 3.2% 0.6% N/A N/A N/AMental Health access rate - clients seen in last 12 months as % of population (64+yrs) 2.4% 2.6% -0.2% N/A N/A N/A


Outpatient - First Specialist : Follow-up Clinic ratio 35% 39% 4% 37% 37% 0%Outpatient - Did Not Attend rates - Maaori 18% 10% -8% 20% 10% -10%Outpatient - Did Not Attend rates - Pacific 18% 10% -8% 18% 10% -8%Theatre List Utilisation 96% 83% 12% 92% 83% 9%Day of Surgery Admissions (DOSA) 92% 90% 2% 89% 90% -1%Day Case Rate (Elective/ Arranged) 72% 65% 7% 72% 65% 7%% Medical Assessment patients with Length of Stay < 28 hours 85% 65% 20% 81% 65% 16%No. Hospital bed days occupied (against forecast open beds) 21,694 22,215 2.4% 222,800 236,275 6.0%No. Length of Stay outliers (LOS >10 days)* 332 302 -9% 3,279 3,029 -8%


% smokers receive smokefree advice / support -Total 97% 95% 2% 96% 95% 1%% smokers receive smokefree advice / support - Maaori 95% 95% 0% 96% 95% 1%% smokers receive smokefree advice / support - Pacific 98% 95% 3% 97% 95% 2%% smokers receive smokefree advice / support - Asian 96% 95% 1% 96% 95% 1%

% Women (45-60yrs) with Breastscreen in 24months - Total 2867 2255 612 68% 70% -2%% Women (45-60yrs) with Breastscreen in 24months - Maaori 309 269 40 64% 70% -6%% Women (45-60yrs) with Breastscreen in 24months - Pacific 462 370 92 77% 70% 7%

Trend by month FY16-17 May-17 Target Var Actual Target VarPatient experience Survey data - month (n=206) and YTD (n=2,390) 83% 90% -7% 79% 90% -11%

Syst

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Year to date

Quarterly Reporting Year to date

P&W

CC Year to date

Effic

ient

Year to date

Year to date

Volumes Screened % Screened in last 24 months

Equi

ty

040


Financial Results – Provider Arm

Actual Budget Variance Variance Actual Budget Variance Forecast Budget Variance

$(000) $(000) $(000)to Prev Mnth

$(000) $(000) $(000) $(000) $(000) $(000)

IncomeGovernment Revenue 4,917 4,674 244 F 56,192 52,101 4,091 F 58,852 56,744 2,108 FPatient/Consumer Sourced 872 1,013 (140) U 9,526 11,101 (1,575) U 10,691 12,126 (1,434) UOther Income 2,683 2,596 87 F 20,752 28,769 (8,017) U 22,990 31,339 (8,350) UFunder Payments 64,417 65,599 (1,182) U 718,228 721,587 (3,358) U 785,009 787,185 (2,177) UTotal Income 72,889 73,881 (992) U 804,698 813,557 (8,859) U 877,542 887,394 (9,853) UExpenditurePersonnel 50,085 50,337 251 F 525,151 533,708 8,557 F 573,252 583,159 9,907 FOutsourced Personnel 1,877 1,116 (761) U 18,848 12,276 (6,572) U 19,656 13,392 (6,264) UOutsourced Clinical 2,377 2,395 18 F 25,815 25,496 (319) U 28,054 27,892 (162) UOutsourced Other 2,563 3,098 535 F 33,497 34,080 583 F 37,064 37,178 114 FClinical Supplies (excluding Depreciation) 10,066 8,898 (1,169) U 98,282 96,282 (2,000) U 106,610 105,109 (1,501) UOther Expenses 5,613 6,108 495 F 65,901 66,902 1,000 F 72,907 72,988 81 FTotal Expenditure (excl Depreciation, Interest and Capital Charge)

72,582 71,951 (630) U 767,494 768,743 1,249 F 837,542 839,717 2,175 F

Earnings before Depreciation, Interest and Capital Charge

308 1,930 (1,622) U 37,204 44,814 (7,610) U 39,999 47,677 (7,678) U

Depreciation 2,676 2,894 218 F 30,545 31,839 1,294 F 33,380 34,733 1,353 FInterest - 1,225 1,225 F 7,865 13,475 5,610 F 7,865 14,700 6,835 FCapital Charge 952 1,512 560 F 15,610 16,637 1,026 F 16,562 18,149 1,587 FTotal Depreciation, Interest and Capital Charge

3,628 5,632 2,004 F 54,020 61,950 7,930 F 57,808 67,582 9,774 F

Net Surplus/(Deficit) Provider (3,320) (3,702) 382 F (16,816) (17,136) 320 F (17,808) (19,905) 2,097 F


$(000) $(000) $(000)to Prev Mnth

$(000) $(000) $(000) $(000) $(000) $(000)

Medical Personnel 15,952 16,177 225 F 168,737 170,500 1,763 F 184,252 186,312 2,060 FNursing Personnel 19,193 18,598 (595) U 200,262 199,616 (646) U 217,790 218,131 341 FAllied Health Personnel 6,753 7,321 568 F 72,208 77,328 5,119 F 79,347 84,462 5,115 FSupport Personnel 2,242 2,354 112 F 24,583 24,002 (581) U 27,004 26,267 (737) UManagement/Administration Personnel 5,945 5,886 (59) U 59,360 62,262 2,902 F 64,859 67,987 3,129 FTotal (before Outsourced Personnel) 50,085 50,337 251 F 525,151 533,708 8,557 F 573,252 583,159 9,907 FOutsourced Medical 839 444 (395) U 8,910 4,886 (4,024) U 9,385 5,330 (4,054) UOutsourced Nursing 424 194 (229) U 4,143 2,139 (2,004) U 4,108 2,333 (1,775) UOutsourced Allied Health 116 11 (105) U 503 122 (381) U 409 133 (276) UOutsourced Support 53 1 (52) U 349 11 (338) U 298 12 (286) UOutsourced Management/Admin 445 465 20 F 4,943 5,118 176 F 5,456 5,584 128 FTotal Outsourced Personnel 1,877 1,116 (761) U 18,848 12,276 (6,572) U 19,656 13,392 (6,264) U

Total Personnel 51,962 51,453 (509) U 543,999 545,984 1,985 F 592,908 596,551 3,643 F


$(000) $(000) $(000)to Prev Mnth

$(000) $(000) $(000) $(000) $(000) $(000)

Central Clinical Services (7,045) (7,439) 394 F (78,876) (79,578) 702 F (86,465) (86,842) 377 FEmergency Medicine and Integration (13,048) (12,499) (550) U (138,315) (136,056) (2,259) U (150,387) (148,512) (1,875) UMiddlemore Central (2,381) (2,461) 81 F (27,015) (25,529) (1,486) U (29,736) (27,905) (1,831) UARHOP (3,473) (3,520) 46 F (36,612) (37,001) 389 F (40,177) (40,433) 255 FMental Health (6,026) (6,046) 20 F (62,439) (62,729) 291 F (68,245) (68,486) 241 FSurgical & Ambulatory (16,221) (16,048) (173) U (169,980) (168,588) (1,393) U (186,023) (184,615) (1,409) UWomen & Child Health (5,747) (5,668) (79) U (61,205) (60,408) (797) U (66,957) (65,959) (999) UFacilities Services (1,969) (1,725) (243) U (18,329) (18,331) 3 F (20,062) (20,062) 0 FProvider Management 57,710 56,852 858 F 631,462 626,866 4,596 F 690,874 683,759 7,115 FInnovations Hub & Ko Awatea (1,516) (1,521) 4 F (15,746) (15,998) 251 F (17,213) (17,451) 239 FIntegrated Care (3,604) (3,627) 23 F (39,762) (39,785) 24 F (43,418) (43,401) (17) UTotal (3,320) (3,702) 382 F (16,816) (17,136) 320 F (17,808) (19,905) 2,097 F

Surplus / Deficit by Division April 2017

Month Year to Date Full Year

Consolidated Statement of Financial PerformanceCMDHB ProviderMay 2017


Personnel Costs By Professional Group April 2017


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Glossary

ACC Accident Compensation Corporation BOY Balance of Year CYF Child, Youth and Family DHB District Health Board FTE Full Time Equivalent MoH Ministry of Health UF Unfavourable WIES Weighted Inlier Equivalent Separation (activity based measurement) YTD Year to Date

Activity Overall YTD acute WIES is tracking 1% lower than contract reflecting a milder 2016/17 winter, lower ED attendances and enhanced capacity in the community, together with a range of Hospital initiatives. The Plastics and Burns variance reflects lower presentations with respect to the Tahitian Burns contract. Overall YTD elective WIES is 4% below contract. Cardiology YTD WIES is 23% behind contract (offset by acute volumes of 105 WIES), followed by Ophthalmology inpatients, 20% lower than contract as a direct consequence of RMO Industrial Action earlier in the year. A steady increase in patient acuity and an increase in ED demand in the latter part of May resulted in an increase in hospital bed occupancy, reporting five red dot days in the second half of the month. This in turn affected patient flow throughout the system, creating delays as reflected in the ED 6 hour target, that demonstrates the busyness of the hospital during this period. Finance

Actual Budget Variance Variance Actual Budget Variance VarianceVolume Volume Volume % Volume Volume Volume %

M00001 - General Medicine Inpatients 1,388 1,460 (72) U -5% 14,964 15,541 (577) U -4%S00001 - General Surgery Inpatients 837 765 72 F 9% 8,728 8,350 378 F 5%S45001 - Orthopaedic Inpatients 691 752 (60) U -8% 7,671 8,207 (536) U -7%W10001 - Maternity Inpatients 590 537 53 F 10% 6,344 5,905 439 F 7%S60001 - Plastic & Burns - Inpatients 507 491 16 F 3% 5,028 5,362 (334) U -6%M05001 - Emergency Medical Services Inpatients 386 422 (36) U -8% 4,192 4,637 (445) U -10%M55001 - Paediatric Medicine Inpatients 252 267 (15) U -6% 2,617 3,024 (407) U -13%W06003 - Secondary Neonatal 269 264 5 F 2% 3,149 2,905 245 F 8%All Others 1,017 952 65 F 7% 10,861 10,271 590 F 6%Total Acute WIES 5,937 5,908 28 F 0% 63,555 64,203 (648) U -1%S45001 - Orthopaedic Inpatients 445 529 (84) U -16% 4,967 5,060 (93) U -2%S00001 - General Surgery Inpatients 363 405 (43) U -11% 4,179 4,055 124 F 3%S60001 - Plastic & Burns - Inpatients 251 249 2 F 1% 2,465 2,489 (24) U -1%S30001 - Gynaecology Inpatients 122 131 (9) U -7% 1,250 1,441 (191) U -13%S25001 - ORL Inpatients 136 134 2 F 1% 1,165 1,342 (177) U -13%S40001 - Ophthalmology Inpatients 107 130 (23) U -18% 1,041 1,297 (255) U -20%M10001 - Cardiology - Inpatients 35 46 (11) U -24% 376 490 (115) U -23%S70001 - Urology - Inpatients 46 35 12 F 33% 349 349 0 F 0%All Others 83 72 11 F 15% 824 758 66 F 9%Total Elective WIES 1,589 1,732 (142) U -8% 16,616 17,280 (665) U -4%

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

ED Presentations 9,602 9,513 89 F 1% 103,763 105,312 (1,549) U -1%Acute Discharges 7,630 7,415 215 F 3% 79,430 80,431 (1,001) U -1%Elective Discharges 1,613 1,823 (210) U -12% 15,713 15,534 179 F 1%

Other Volumes May 2017 (compared to previous year)

Month Year to Date

Year to DateVolumes May 2017

Month

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The Provider Arm produced a $382k favourable result against budget for the month of May 2017, YTD $320k favourable. YTD variances are explained below. Revenue

Overall revenue is $8.9M unfavourable YTD. A delay in the opening of the new retail pharmacy (opened 7 February 2017) and slower than anticipated retail sales to date has contributed $6.4m to the YTD shortfall ($564k unfavourable for the month), offset by a YTD underspend in cost of goods sold (other expenses). Delayed Middlemore Foundation donation revenue ($1.3M) and fewer Tahitian burns presentations ($1.4M) continue to present a challenge YTD. The on-going success of the ACC arrears initiative and ACC Treatment Injury has softened this impact YTD. In the main, these specific revenue variances have little impact on operating cost. A change to MoH DHB debt equity policy on 15th February 2017 has resulted in a $1.2M reduction in interest expense for May, offset by a commensurate reduction in the MoH revenue. The remaining months of the financial year will see no interest charged to the DHB’s but there will be an equal offset to the MOH monthly revenue. The change from Debt to Equity will start from 1 July 2017 with the DHB’s being compensated for the difference in capital charge (6.0%) and the DHB average interest rate via way of increased revenue for the next two years only. This change is consistent across all DHB’s.

Expenditure

Overall operational expenditure is favourable $1.2M YTD. Key expenditure variances are summarised below: Personnel Costs ($8.5M favourable YTD, Outsourced Personnel $6.6M unfavourable) Variances in Personnel Cost categories (net of outsourcing) were as follows: • Net Medical staff costs are $2.2M unfavourable YTD.

SMO costs associated with the October and January RMO industrial action ($1.3M net of RMO non-payment YTD) has been covered by existing medical vacancies to May 2017. The $2.2M YTD unfavourable result reflects the following: - Night cover for Women’s Health ($458K YTD) as a result of a full year $500K budget error that is being

managed through a number of initiatives, including the Maternity Ward Project (Living our Values) to mitigate the financial impact of unfavourable YTD costs.

- Difficulty in attracting qualified psychiatrists to the DHB has led to a $1.95M underspend in Mental Health medical staff costs, offset by outsourced medical costs for locum cover, $3.2M (net $1.25M YTD unfavourable).

- RMO Industrial action mentioned above, YTD net cost $1.3M.

- Existing medical staff vacancies across the clinical services have reduced the impact of unplanned

expenditure above.

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• Net Nursing staff costs are $2.6M unfavourable YTD; reflecting bureau use to cover high acute demand, particularly in the Neonatal unit, Surgical Services, Medicine and ARHOP. This includes YTD spend on the delirium project which will facilitate better management of patients and consolidation of watch capacity.

• Net Allied Health staff costs are $4.7M favourable YTD; driven by a shortage of anaesthetic technicians in the first half of the year $600K, together with a shift of multidisciplinary Mental Health community work to nursing. Continued vacancies across many areas of Allied Health makes up the balance.

• Net Support personnel costs are $919k unfavourable YTD; predominantly reflecting overspends in cleaning, orderly and security services. This variance is driven by an understated budget for penals. Notwithstanding this, the service has introduced a proactive performance management structure for these services encompassing performance management, management of sick leave, overtime and annual leave.

• Net Management and Administration staff, $3M favourable YTD, reflects vacancies in the Community teams

together with other vacancies held across all other services. High levels of annual leave taken over the Christmas/New Year period (including extended leave for non-essential staff) and a deliberate strategy for staff with leave balances >2 years to take annual leave, has had a positive impact on the YTD position.

Non Staff Costs

• Clinical supplies are $2m unfavourable YTD, driven by a high demand in pharmaceuticals, $1.7m unfavourable, particularly in Immunosuppressant’s. Bloods are $1.1M favourable reflecting a lower demand for blood transfusions. Unbudgeted operating lease costs associated with KAII of $1M have been offset by depreciation. The balance of the variance is made up of YTD unrealised target savings, $591k.

The month variance of $1.17M unfavourable for May reflects a continuing high demand of pharmaceuticals of $395k, together with a two month catch-up for operating lease costs associated with the KAII build $624k (offset by depreciation).

• Other Expenses are $1m favourable YTD; reflecting reduced cost of goods sold associated with the delayed

opening of retail pharmacy, offset by investment in Community Health Services Integration, on-going exposure relating to the national food contract and repairs and maintenance.

• Interest, Depreciation and Capital Charge costs are $7.9M favourable YTD; as outlined above, the change

from debt to equity funding has contributed $3.6M YTD that will be offset by a reduction in MoH revenue. Depreciation is $1.3M favourable YTD, reflecting a delay in the 2016/17 Capital programme.

Looking Ahead

System level measures have been introduced across Counties Manukau Health, ensuring aligned focus on the areas of our business most amendable to improvement. This combination of interventions, together with an enhanced Service Planning and Performance team will improve patient flow and utilisation of capacity, slowing the growth in bed demand going into autumn and winter enabling us to continue to run with YTD staffing resource. The YTD cost of two periods of RMO industrial action has amounted to just over $1.3M. Outsourcing to deliver lost elective capacity is forecast at $700K. These costs add additional pressure to an already challenging financial position. Despite this, Provider services are working closely with the Funder to deliver to the overall organisation target surplus of $0.5M. The above measures, combined with continued delivery against our target benefit plan will enable the Provider to meet a full year deficit forecast of $17.8M (budget deficit $19.9M).

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Emergency Department, Medicine and Integrated Care Glossary

CNM Charge Nurse Manager DNA Did Not Attend ED Emergency Department FCT Faster Cancer Treatment FSA First Specialist Assessment GP General Practitioner/General Practice MA Medical Assessment MoH Ministry of Health MSC Manukau SuperClinic RMO Resident Medical Officer SMO Senior Medical Officer STEMI-PCI ST-elevation Myocardial Infarction Percutaneous Coronary Intervention YTD Year to Date Service Overview

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

National Bowel Screening Programme – rsegular update for the Hospital Advisory Committee The Committee asked for a “Bowel Screening Programme regular update via the Medicine report each meeting” to be provided. For the National Bowel Screening Programme, CM Health has submitted information required for the business case to MoH. MoH has signalled that there will be ongoing discussions on CM Health’s proposed model of care and the level of resource required to be funded, to ensure a successful programme which provides equity of access for our population. We are now waiting on further discussion with MoH which will enable us to finalise the model of care and funding that will then give us a basis to appoint a project manager. Breastscreening for Maaori and Pacific women During the Hospital Advisory Committee meeting held on 31 May 2017, it was requested that the division “report back with an update on the issues associated with why it is so difficult for Maaori & Pacific women to get their breast screening done”. BreastScreen coverage for Pacific women is currently 76.2%, exceeding the national target of 70%. While on occasions, monthly screening volumes for Pacific women may not meet target, overall the service always exceed all contracted volumes for Pacific women. As at 30 May 2017, total volumes for Pacific women were exceeded with 3,985 delivered (YTD target 3,700), and YTD contracted volumes for Pacific 50-69 years were also exceeded with 2,914 delivered (YTD target 2,460). Nationally coverage is below target for Maaori women. BreastScreen Counties Manukau commenced a project in 2016 to increase Maaori coverage. Initially the service ran focus groups with Maaori women, funded by CM Health Maaori Health, to identify barriers to screening and to

045


assist with the development of key messages and a strategy to increase participation in breast screening. The service then asked three media companies to develop a campaign based on the feedback from the women. A social marketing campaign then commenced in May 2017, including TV advertisements on Maaori TV and radio advertisements on stations, which the focus group women and media surveys show that our Maaori women listen to most. We have arranged trailer billboards in areas where the mobile unit is due to visit, and advertising on two buses which predominantly travel on South Auckland routes. Funding for this campaign was approved by BreastScreen Aotearoa to utilise BreastScreen Counties Manukau surplus funding. In conjunction with the media activity, the service has been intensively following up Maaori DNA/DNR women. Monthly screening volumes for Maaori women have been exceeded each month from March 2017; as BreastScreen coverage is a measure over 24 months it will take a few months to increase coverage to target level. Highlights

GP/ED wait times – Healthpoint There is currently little (or no) visibility of patient wait times in either general practices, Accident and Medical clinics, or emergency departments for consumers and therefore little opportunity for providing informed choice in seeking the timeliest health care option. Healthpoint has recently signed a contract with CM Health to determine if it is possible to receive and utilise patient waiting time data from GP practices and Accident and Medical clinics in Counties Manukau and the Middlemore Hospital ED. This would enable Healthline to advise callers of patient wait times through the Healthpoint profiles, so that patients can determine the most timely health care option. The wait time information would also be available to patients when they view profiles for local practices and our ED through the Healthpoint website. An evaluation will look at whether this causes a change in health seeking behaviours that lead to unnecessary ED presentations. Emerging Issues

Emergency Department

Presentations During May, ED presentations totalled 9,602 which is a 0.9% increase over last year’s volumes for the same month. YTD presentations are 113,167 which represents a 1.17% reduction from the same time last year, following a mild winter. In contrast, we have experienced a significant spike in presentations during June. Both adult and youth presentations have increased at a concerning rate throughout the month, and at a level unprecedented for the same period in previous years. Significant system-wide effort has gone into creating additional bed capacity, increasing staffing levels to manage demand, and improving bed turnaround times to assist with patient flow.

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Performance against the six hour national target Our performance against the six hour target was excellent up to March 2017; however, performance for the quarter ending 30 June 2017 will not meet target. This is due to significant pressure on patient flow within the hospital as a result of higher patient volumes over the past two months. Key issues that we are currently addressing include:

• Better matching our people resource to patient flow. • Patients spending more time in ED short stay units because of lack of flow in the hospital. • We are currently developing metrics that show internal access block within the system. • Our trigger tool data shows that patient arrival density (or surges) is now more frequent

which means that at peak times with current resources it is very challenging to manage flow with ED.

Emergency Q ED has agreed to pilot Emergency Q for three months; this is a system that has recently been piloted at Waitemata DHB. The system creates live data driven connection between patients, primary care providers, and hospital emergency departments. The aim is to take pressure off over-stretched hospital emergency departments by actively supporting diversion of non-emergency patients to urgent/primary care clinics. The patient benefits are:

• See and compare live actual wait and treatment times (hospital/ primary care) – access right care, faster

• Educating patients about what types of medical conditions they should go to hospital for (and what they should see a GP for)

• Locate nearest available primary care providers (data aggregator) • Join primary care queues/make appointment remotely from wherever you are • Access ancillary services and save time

Benefits to the ED include:

• Step-change in reducing numbers of non-emergency patients in the ED • Enables targeting of hospital resources at patients from higher needs communities through

Precision Equity tool • Empowers frontline triage nursing teams to support patient decision making • Frees up ED staff to focus their time, training and skills on emergency patients • Direct communication channel with patients (at “personal” and “population” level) • Safety: live tracking patient’s complete treatment journey

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Benefits to Primary Care include: • Prescription tracker to identify when patients haven’t converted prescriptions • Opportunities to grow scale of service and care for new groups of patients (not previously

accessing primary care) Update on previously reported issues

Issue Date reported Update

Gastroenterology – challenge of maintaining FCT and MoH targets.

19 Oct 2016 We continue to experience high levels of demand which has been up to 33% increase per month from January. For May this has tapered off with referrals up by 11.4 % compared to the same time last year. Work continues to try and increase capacity within the Gastro department and meet targets. To date we have employed two more SMOs, who have commenced in March and May. We continue to recruit for a fellow and have offered a position to a potential candidate to start in December this year. The SMOs on sabbatical and maternity leave have now returned. We have also increased the in-house capacity with more SMOs agreeing to do additional lists. We are currently negotiating to re-commence Saturday lists. We have completed another round of outsourcing to private providers. We also negotiated with the MoH National Bowel Screening Programme for an extension on the date for achieving the targets and still receive the additional funding for reducing colonoscopy waiting lists.

Lung Function Lab Accreditation

31 May 2017 Options are being explored for alternative testing space. Discussions held with lab and Surgical Services staff around possible use of the laboratory space at MSC.

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Trend Rating Commentary (by exception)FY16-17 May-17 Target Var Actual Target Var

Total Caseweight 2,453 2,563 -4.3% 26,673 27,542 -3.2%

Elective Caseweight 67 81 -17.3% 608 867 -29.9%Mostly due to Cardiology & Gastro. Cardiology volumes are offset by corresponding over performance in Acutes.

Acute Caseweight (includes Intensive Care Unit) 2,385 2,482 -3.9% 26,065 26,675 -2.3%Variance is due to slightly lower volumes month to month than previous years. However have seen increased volumes in June and this variance may reduce.

Outpatient First Specialist Assessment (FSA) Volumes 1,695 1,582 7.1% 15,496 15,252 1.6%Outpatient Follow Up Volumes 4,089 3,541 15.5% 36,917 37,476 -1.5% Custom clinics continue to be run to improve volumesVirtual First Specialist Assessments (FSAs) 145 152 -4.6% 1,988 1,654 20.2%

Trend Rating Commentary (by exception)FY16-17 Apr-17 Target Var Actual Target Var

% Staff with Annual Leave > 2 years 2.4% 5.0% 2.6% 7.1% 5.0% -2.1%Continue to monitor annual leave >2 years across all services, and have a positive result for the month.

% Staff Turnover 11.1% 10.0% -1.1% 10.2% 10.0% -0.2%% Sick Leave 3.8% 2.8% -1.0% 3.1% 2.8% -0.3%Workplace Injury per 1,000,000 hours 7.1 10.5 3.5 11.8 10.5 -1.3


No. Falls causing major harm 0 0 0 2 0 2 No falls for the month


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

% of patients admitted, discharged, transferred from ED within 6 hrs 93% 95% -2% 94% 95% -1%High volume of dot days - unable to move patients through the hospital , an average of 20 patients waiting for beds daily with a high of 47

P1 (urgent) % diagnostic colonoscopy patients receive the procedure within 14 days 96% 85% 11% 96% 85% 11%

P2 (routine)% diagnostic colonoscopy patients receive the procedure within 42 days 58% 70% -12% 66% 70% -4%

P2 target not achieved due to a number of things experienced since December including, 3 SMOs going back to Gen Med cover, 3 SMOs in sabbatical and maternity leave, a senior fellow vacancy, RMO strike actions and an unprecedented increase in referrals at approx. 30% for the last 5 months. This has been rectified partically with 2 new SMOs, private outsourcing and re-commencing additional lists.

% surveillance colonscopy patients receive their procedure within 84 days of planned date 93% 70% 23% 81% 70% 11%% cardiac STEMI - PCI (angiography) within 120 mins - Northern Region Target 100% 80% 20% 86% 80% 6%

% Coronary Angiography within 90days (1 month in arrears) 85% 95% -10% 94% 95% -1%

A build up of elective cases due to equipment issues in previous months, combined with high acute demand and a single Cath Lab impacted on meeting the target this month.

Medical Assessment – Triage 3-5 patients seen within 60 minutes 71 60 11 90 60 30 Reflects business of MA and increase workload

Door to Cathlab suspected Acute Coronary Syndrome < 3 days (median time) 66% 70% -4% 79% 70% 9%High acute load combined with need to reduce elective wait list constrained by the single Cath Lab resulted in missing the target this month.

EMERGENCY DEPARTMENT, MEDICINE AND INTEGRATED CARE SCORECARDEn

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May 2017

Variance not significant enough to consider offtrack

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12 month average

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General Medince - Seen By Time (minutes)

1st Time to be seen Triage 1 & 2 patients (median time in minutes) 36 30 -6 31 30 -1Performance is mostly on target. Small variation this month, likely to be due to high volumes this month compared to others

1st Time to be seen Triage 3 - 5 patients (median time in minutes) 83 60 -23 80 60 -20 Reflects business of MA

2nd Time to be seen Triage 1 & 2 patients (median time in minutes) 63 30 -33 56 30 -26

Not meeting target and the performance for this metric is influenced by a number of factors including methods of patient handover that result in batching of patienst referred. A review of the data will be done for this process to examine where are the points in the day that the timliness of the service is not met.Once this is establised the cause of the delay will be expored. Project is underway.

2nd Time to be seen Triage 3-5 patients (median time in minutes) 73 60 -13 69 60 -9

A similar approach as above to identifying the periods of the day that this process is not being timely will undertaken. This will provide insight into the reasons for non performance and help identify solutions

Faster Cancer Treatment - % high suspicion first cancer treatment within 62 days - MOH Faster Cancer Treatment

81% 85% -4% 77% 85% -8%

Performance over the past 3 months has lifted to 84%. Patient and pathway mircomanagement continue, and recruitment to enhance tracker roles has been completed. This will provide greater drive to ensure all patients are managed in as timely manner as possible.

Faster Cancer Treatment - %confirmed diagnosis first cancer treatment within 31 days - MOH Faster Cancer Treatment

89% 85% 4% 88% 85% 3%


Average Length of Stay - Acute 3.2 3.5 0.3 3.1 3.5 0.4

Acute Readmissions within 28 days - Total 13% 10% -3% 13% 10% -3%

This month acute 28 readmissions was 13% - It should be noted that 36 out of the 133 patients that were readmited were seen and sent home from ED/MA. Therefore while the rate is higher, some of these patients are not actually readmited to the ward but were representations.

Acute Readmissions within 28 days - 75+ 13% 10% -3% 14% 10% -4%

Rate of readmission improved this month and is not significantly higher than expected. 8 out of 47 patients were seen and discharged from ED/MA so are not true readmissions.

% of patients on home wards in General Medicine 46% 75% -29% 45% 75% -30%

May occupancy in home wards improved slightly. The overall occupancy for general medicine in May was 119%, significantly higher than previous months. With demand being greater than bed capacity, patients had to be placed in outlier wards . Additionally, to reduce the impcat on MA and ED patients had to be placed where beds were available. The SMO and RMO roster change proposal is underway to enable better operation of the home ward based system. Once the rosters are implemented, this is likely to improve provided the hospital occupancy enables the wards to handle additiona capacity. However, with winter demand there will be need to outlie patients to meet capacity

% of Outliers on non-medicine wards 4.0% 0.0% -4.0% 6.6% 0.0% -6.6%

The demand was greater than capacity this month for most days. Average occupancy was 119% thsi month which meant patients have had to be admitted to areas other then medicine to meet the demand. Capacity for this demand can only be managed through outying in areas where beds are available.

Syst

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% Discharges from transit lounge or home by 1100hrs 20% 30% -10% 17% 30% -13%

The 11 am discharge rates have improved and been sustained over the last 3 months. Overall trend indicates a steady move towards the target with gradual improvement. 3 pm rapid rounds and nurse faciliatated discharges are strategies currently being used. Doctor roster changes will also result in timely decsion making to support early discharges. Work is also currently being done with CNMs and ward teams to increase the awareness of the need for early discharges as well as identifying reasons for why discharges are delayed. Note this data is for all medicine wards not just general medicine. General Medicine rates are higher

% Discharged from Medical Assessment Unit by 1100hrs 43% 40% 3% 40% 40% 0%% of patients < 28 hrs discharged from inpatient wards 10% 10% 0% 10% 10% 0%Implement Home First Renal policy - (increase Continuous Ambulatory Peritoneal & HD rate) 44% 50% -6% 43% 50% -7% Ratio of Home:Incentre dialysis for May is up by 1% on April

to 44%:50%. This is due to there being 12 less patients on dialysis overall in May, with 11 less patients on incentre haemodialysis and 2 less on peritoneal dialysis, but 1 more on home haemodialysis. There were 2 transplants in May, both patients from incentre dialysis.


% Women with Breastscreen in last 24 months - total 2867 2255 612 68% 70% -2%% Women with Breastscreen in last 24 months - Maaori 309 269 40 64% 70% -6%% Women with Breastscreen in last 24 months - Pacific 462 370 92 77% 70% 7%


Patient experience Survey data - month (n=32) and YTD (n=441) 81% 90% -9% 80% 90% -10%

Effi

cien

tYear

Equi

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Volumes Screened % Screened in last 24 Months

We now have additional capacity, monthly targets are being met and coverage slowly increasing. As this is a 24 mth measure, coverage increases slowly.

P&W

CC Year to date

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Surgery, Anaesthesia and Perioperative Services Glossary

CLAB Central Line Associated Bacteraemia DNA Did Not Attend ESPI Elective Services Patient Flow Indicator FSA First Specialist Assessment GP General Practitioner/General Practice ICU Intensive Care Unit MMH Middlemore Hospital MoH Ministry of Health MSC Manukau SuperClinic RMO Resident Medical Officer VTE Venous Thromboembolism WIES Weighted Inlier Equivalent Separations YTD Year to Date Service Overview

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

Theatre Performance Elective theatre utilisation performance over both sites (Middlemore Hospital and Manukau SuperClinic) continues to exceed 85%.

Discharges Acute discharges are 87 cases higher than contract for the month and 367 (2.03%) higher than contract year to date. Elective discharges are also higher than contract by 45 patients (3.22%) and 95 patients (0.68%) ahead year to date.

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Overall patient discharges are 131 higher than contract for the month and 462 year to date. We are on track to deliver our discharge target. Green ESPI has been achieved for this month. Early Supported Discharge The percentage of patient discharges before 11.00am reached an average of 30% per day (1406 patients) for the month of May within the division. Did Not Attend (DNA) rates The division continues to maintain a low overall outpatient DNA rate at 9%. Urology had the lowest outpatient DNA rate at 3.9% for overall DNA. Sound processes within the division continue to see DNA rates reducing. Update on previously reported issues

Issue Date reported Update Critical Care beds under increasing demand

27 Jul 2016 Critical Care occupancy though out May was steady. The High Dependency Unit booking referral process is ensuring early recognition of bed requirements – this project is ongoing.

Demand on Ophthalmology and Otorhinolaryngology (ORL) services

27 Jul 2016 MoH follow-up volumes reporting begun as at the end of May 2017. The Division’s General Manager has joined the National Ophthalmology Service Improvement Expert Advisory Group. The new Galbraith building facility will give the service an additional three clinic rooms, and will hold its first clinic on 27 June 2017.

Potential machinery failure in the MSC Sterile Supply Unit

8 Mar 2017 The MSC Sterile Supply Unit is at risk of failure due to ageing machinery. A mitigation plan is in place, and a plan is in place to progress required remedial work.

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Total Caseweight (Provider view) 3,576 3,591 -0.4% 36,960 37,596 -1.7%Elective Caseweight 1,477 1,515 -2.5% 14,870 14,923 -0.4%

Acute Caseweight 2,099 2,076 1.1% 22,090 22,673 -2.6%Will not be achieved as contract has not been adjusted down for change in WIES between WIES 15 and WIES 16.

Acute discharges 1,739 1,652 5.2% 18,413 18,046 2.0%Elective Surgical Discharges 1,446 1,401 3.2% 13,908 13,813 0.7%

Virtual FSAs/Follow ups -(GP consult and nonpatient appointments) 140 159 -11.8% 1,475 1,613 -8.6%This measure is improving month on month as strategy is in place to improve.

Personnel Costs ($000) $13,037 $13,343 2.3% $140,406 $141,885 1.0%Financial Result Total ($m) $16,221 $16,048 -1.1% $169,980 $168,588 -0.8%

Reduce clinical outsourcing ($000) $629 $403 -56.0% $5,426 $3,629 -49.5%


% Staff with Annual Leave > 2 years 15.1% 5.0% -10.1% 22.0% 5.0% -17.0%Working through this project to reduce high level balances. Monthly reporting by Service Managers.

% Staff Turnover 10.4% 10.0% -0.4% 12.3% 10.0% -2.3%Slightly over for this month however overall stability at present

% Sick Leave 3.1% 2.8% -0.3% 3.4% 2.8% -0.6%Sick leave is being managed well with very small discrepancy for this month

Workplace Injury per 1,000,000 hours 0.00 10.5 10.5 8.80 10.5 1.7


Hand Hygiene compliance rate (based on Gold Audit) - Ward 11 74% 80% -6.0% 73% 80% -6.6%Mitigation Strategy is in place - training gold auditors from ward staff.

Pressure Injuries / 100 patients 0.00 0.00 0.00 0.00 0.00 0.00Falls causing major harm / 1000 bed days 0.00 0.00 0.00 0.00 0.00 0.00Severe Pressure Injury (ungradeable) per 1000 bed days 0.00 0.00 0.00 0.00 0.00 0.00Surgical Site Surveillance for Major joints-

Antibiotics given 0-60mins before "knife to skin" 91% 95% -4% 89% 95% -6%

2 grams or more Cefazolin given 95% 100% -5% 97% 100% -3%

Appropriate skin preparation 100% 100% 0% 99% 100% -1%

CLAB rate/ 1000 line days 1.0 0.0 -1.0 0.1 0.0 -0.1 One ICU patient - no known cause - still investigating.

Rate of S. aureus bacteraemia per 1000 bed days 0.1 0.0 -0.1 0.1 0.0 -0.1 Within tolerance.VTE - Ortho (Acute and Elective) 9.0 2.0 -7.0 76.0 0.0 -76.0 Each case will be reviewed by VTE committee.

We have discovered an issue with the timing on Anaesthetic machines which is not synchronised with other theatre clock. Will rectify with Biomedical team.

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Pre-operative Length of Stay Days (from admit to surgery) 1.2 1.0 -0.2 1.2 1.0 -0.2 We continue to work on reducing this number.ESPI 2 No. patients waiting >120 days for FSA - Elective (Surgical Services incl Gynae)

0 0 0 0 0 0

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

3 0 -3 3 0 -3 Three patients will be treated in June.


Average Length of Stay - Acute Inpatient incl Burns 3.84 3.8 0.0 3.73 3.8 0.1Average Length of Stay - Acute Inpatient excl: Burns 3.83 3.8 0.0 3.71 3.8 0.1Average Length of Stay - Acute Inpatient excl: Burns and Spinal Ortho 3.79 3.8 0.0 3.70 3.8 0.1Average Length of Stay - Electives 1.07 1.5 0.4 1.20 1.5 0.3


Theatre list utilisation - % used MMH/MSC (MOH OS5) 95% 85% 10% 91% 85% 6%Theatre session utilisation - % used MMH/MSC 99% 95% 4% 94% 95% -1%Elective Theatre turnaround times- Mins (MSC only) 16 15 -1 16 15 -1

Elective cancellations - Day of surgery as % of all Elective (all reasons)- SAPS only

8.8% 5.0% -3.8% 8.2% 5.0% -3.2%

Day of Surgery Admissions (DOSA) 92% 90% 2% 89% 90% -1%Day Case Rate (Elective/ Arranged) -Subspecialties in SAPS only Adults/kids 72% 65% 7% 72% 65% 7%MMH % patients discharged to discharge lounge or home by 1100hrs 30% 30% 0% 22% 30% -8%MMH % patients discharged to discharge lounge or home by 1100hrs -GEN SURG 34% 30% 4% 25% 30% -5%

MMH % patients discharged to discharge lounge or home by 1100hrs- ORTHO 21% 30% -9% 17% 30% -13%Greater improvement sought from Orthopaedics - highlighted to Service Manager.

MMH % patients discharged to discharge lounge or home by 1100hrs- PLASTICS 34% 30% 4% 20% 30% -10%Ratio FSA/Follow-up clinic ratio 34% 31% 3% 38% 31% 7%Outpatient DNA rates - overall- Surgical Services only 9% 10% 0.9% 9% 10% 0.6%Outpatient DNA rates - Maori (FSA) - Surgical Services only 14% 10% -4.2% 16% 10% -6.4%Outpatient DNA rates - Pacific (FSA)- Surgical Services only 15% 10% -5.1% 15% 10% -5.2%


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

93% 95% -2% 95% 95% 0%


Patient Experience Survey - month (n=103) and YTD (n=1066) 97% 90% 7% 81% 90% -9%Month total exceeds expectations. N = number of patients who rated their experience as 'very good' or 'excellent'

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Central Clinical Services Glossary

CAR Corrective Action Recommendation CSF Cerebrospinal Fluid CT Computed Tomography ED Emergency Department ELT Executive Leadership Team ESBL Extended-Spectrum Beta-Lactamases ESR The Institute of Environmental Science and Research eMR Electronic Medication Reconciliation FNA Fine Needle Aspiration FTE Full Time Equivalent IANZ International Accreditation New Zealand KPI Key Performance Indicator MRI Magnetic Resonance Imaging MRT Medical Radiation Technologist PT/INR Prothrombin Time/International Normalised Ratio SMO Senior Medical Officer YTD Year to date Service Overview

The Central Clinical Services division is managed by Ian Dodson (General Manager), with Clinical Directors/Heads Dr Ross Boswell (Laboratory), Dr Sally Urry (Radiology), Dr Mary Christie (Histopathology), and To’a Fereti (Clinical Nurse Director). Highlights

Pharmacy – Influenza Vaccination Uptake 100% of Community Pharmacy staff and 77% of Inpatient Pharmacy staff have had their influenza vaccination this year; these uptake rates are above average. Radiology Approval from the CM Health Board was received to replace the primary interventional radiology equipment in the department. The new equipment will result in more accurate imaging and will improve clinical outcomes for procedures. Planning is now underway around the facilities management for the changeover of equipment and engagement will start with impacted services around managing the shutdown period. Laboratory Four staff members attended the annual NZ Blood Service scientific seminar. Staff attending the seminar are required to either submit a poster or give a 10 minute presentation at the seminar. CM Health staff were awarded prizes for best poster of the seminar, and Jinny Ng was awarded “Most promising scientist” from the oral presentations.

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Emerging Issues

There are no emerging issues to report for the month of May. Update on previously reported issues


Reduced Radiologist FTE

7 Sep 2016 There has been one new FTE commence in May, and the vacancy rate is now just below 20%. As reported previously, FTE will improve throughout June with three radiologists starting. Current predictions, without additional confirmed positions, identify a FTE shortfall of four FTE until February 2018. We are working hard to recruit to fill these positions. The service is being covered by running additional sessions, and outsourcing some scans and reads to manage the volumes.

General x-ray service 7 Sep 2016 Significant effort has been put into meeting the higher than anticipated demand, and the waiting times have improved. The ability to report plain film examinations in a timely fashion remains challenging with the current resource levels. Remote reporting at a Radiologist’s home has started and other opportunities are being explored to widen this capability. It is expected with the additional FTE starting and some outsourced reporting starting in June that the number of outstanding reports will reduce significantly.

Histopathology Lab 8 Mar 2017 HAC visited the Histology Laboratory in May as part of a tour of a number of areas of the hospital. Work is continuing on a revised option to move the service to the Ground Floor of the Galbraith building in the site formerly occupied by the old laboratory that was vacated in 2016. A business case will be presented to ELT in early July and AR&F in August. Regular updates are being provided to IANZ on progress to rectify the CAR. IANZ are happy with the current progress.

Unavailability of consumables for ESR tests

31 May 2017 This issue has now been resolved. The lab has an ongoing source for supplies for ESR tests.

Rapid reduction in MRT workforce

31 May 2017 There has been an increase in the MRT vacancies for reasons previously reported. An international recruitment campaign is underway and the radiology service is working closely with recruitment to attract further candidates. Whilst there has been two recent appointments there is still likely to be eight vacancies this month. Existing staff are covering vacant shifts to ensure the service is maintained. Currently all sessions are still being delivered with current resources.

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Responses to Action Item Actions previously assigned by the Hospital Advisory Committee are reported back on in this section. HAC Meeting 31.5.2017 – Histology “Provide an update on the regional options analysis review currently underway”. The three Auckland Region DHB Histology Services met together in May to have a combined regional discussion around the issues currently facing all of the DHB Histology laboratories. All three DHBs currently have CARs in place by IANZ, the national auditing body, around the constrained status of the accommodation in the laboratories. Auckland DHB also had a CAR around formalin fume levels being too high. An outcome of the meeting was to provide a regional briefing paper to the Regional Service Review Group outlining the current status of each DHB’s laboratory and the options that they are currently pursuing to rectify the accommodation issues. This briefing paper has been submitted and will be reviewed at the next meeting. Since the submission of the paper, Auckland DHB has had their laboratory accreditation suspended due to lack of progress in resolving their issues around formalin fume levels and their general laboratory accommodation. CM Health is currently completing a revised business case on a proposed solution that will rectify the current accommodation issues and ensure that the CM Health Histology lab is compliant and provides a safe working environment for staff and ensures optimal management of specimens being handled in the lab. This business case is expected to be submitted to ELT for review in early July. The CM Health laboratory team are providing regular updates to IANZ around our progress to resolve the accommodation issues, and IANZ are satisfied that CM Health is making sufficient progress. HAC Meeting 31.5.2017 – Food Service “Provide an action plan on how the Food Service is going to get the patient response rates up”. Background Currently, patient experience of food is captured in a number of ways:

• Formal feedback through monthly surveys conducted by Compass – this captures quantitative feedback and patient comments, as well as nursing staff feedback.

• Formal feedback through CM Health’s post-discharge survey in the Cemplicity system – this captures quantitative feedback and patient comments, and normally has a very low response rate.

• Complaints and compliments – received directly from the patients or via ward staff. • Dietitian or Speech Language Therapist feedback.

Response rate The CM Health Food Services team has met with Compass to discuss the low response rate from their regular monthly surveys. The low response rate makes it difficult to get a consistent picture of patient experience. The low response rate is an issue that Compass have already been putting some effort in to addressing in the past few months. The following actions have been agreed between CM Health and Compass:

• Compass to review their survey administration to improve survey response rates • A minimum number of completed survey responses of 40-50 per month has been agreed

(approx. 30% response rate). This is currently being reviewed by NZ Health Partnerships so may require future amendment.

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• A second round of surveys will be administered if the total number of responses does not reach the minimum level.

• Further surveys will be administered if there is no response from any of the individual monthly target wards.

Patient experience Currently the only information being circulated about patient experience of food is the summary ranking of the post discharge CM Health patient experience survey. It shows a summary of all feedback received over 12 months. This generally shows the feedback on the overall rating of food as being quite poor. To get a better overview of the patient experience of food we will undertake with Compass to present the survey results of both the Compass and Organisational Patient Experience surveys side-by-side. The overview will cover the following areas:

• The Compass and Organisational headline food ratings will be presented side-by-side on a monthly basis, showing trend analysis.

• We will apply the current Compass KPI of 90% of patients satisfied or very satisfied. • A breakdown will be provided on the ratings in the patient experience specific questions

from the Compass surveys. • The qualitative feedback from both the Compass surveys and the CM Health surveys will be

categorised using the same categories and presented side-by-side. • An action plan detailing quality improvement work being undertaken by CM Health and

Compass will be provided in the report. Compass currently have a matrix that all of the feedback is entered in to which guides improvement work.

• The report will be provided to HAC through the Central Clinical Services section of the Hospital Services monthly report.

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% Staff with Annual Leave > 2 years 9.6% 5.0% -4.6% 9.3% 5.0% -4.3%Leave plans continue to be put in place for those with high leave balance. Short staffing in radiology is impacting on the ability of remaining staff to take leave.

% Staff Turnover 2.1% 10.0% 7.9% 6.1% 10.0% 3.9%% Sick Leave N/A 2.8% N/A N/A 2.8% N/AWorkplace Injury per 1,000,000 hours N/A 10.5 N/A N/A 10.5 N/A


% eMR completed for high risk patients within 48hrs 74% 80% -6% 68% 80% -12%93% of high risk patients received an eMR during their stay. Ongoing work happening to improve pharmacy presence at the front of hospital


% MRI scans completed within 6 weeks from acceptance of referral 78% 85% -7% 79% 85% -6%

Target won't be achieved in this fiscal year, plans to address asfollows.Demand greater than capacity to deliver due to SMO and MRTvacancies and reduced elective lists. Recruitment is ongoing for MRT'sand radiologists. Outsourcing is continuing, however current outsourced volumes are not being delivered within the time frames required.Additional clinics will be added as resource allows. MRI is beingprioritised within radiology modalities

% CT scans completed within 6 weeks from acceptance of referral 96% 95% 1% 97% 95% 2%Radiology - Inpatient radiology times < 24hours 93% 95% -2% 94% 95% -1%

Radiology ED radiology times < 2 hours 95% 95% 0% 93% 95% -2%Laboratory -Test turnaround time (TAT) within 60mins

Potassium 96% 90% 6% 95% 90% 5%Haemoglobin 99% 98% 1% 99% 98% 1%PT/INR 98% 98% 0% 98% 98% 0%Troponin 1 for ED 95% 90% 5% 93% 90% 3%

Histology - All - 5 working days 88% 90% -2% 85% 90% -5% Continuing to improve, close to target for the monthBreast - 3 working days 95% 80% 15% 89% 80% 9%Non gynae FNAs - 3 working days 92% 90% 2% 90% 90% 0%

Blood Bank - antibody screen within 4 hours 93% 90% 3% 93% 90% 3%Microbiology

CSF cell count <30mins 97% 90% 7% 95% 90% 5%ESBL screens <2days 96% 95% 1% 95% 95% 0%CDT (C. diff Toxin) <25hrs 85% 90% -5% 85% 90% -5% Under target but not a front line urgent test

UCHM (Urine Chemistry) <60mins 86% 90% -4% 86% 90% -4%Process changes have been implemented. Under close scutiny to improve performance

% radiology results reported within 24 hours 49% 75% -26% 58% 75% -17%

Target won't be achieved in this fiscal year, plans to address as follows. Reporting in the modalities where Radiologists are present in the sessions remains high. However, general x-ray reporting is lagging due to the 20% vacancies in the Radiologists team. Remote reporting has started. Further remote reporting is planned.


% transcribed clinical summaries (meddocs) authorised <7 days of creation 72% 95% -23% 72% 95% -23%Continuing to engage through clinical leadership groups and clinical forums to improve turnaround time

Small variances compared with the previous month across all modalities

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Kidz First and Women’s Health Glossary

ALOS Average Length of Stay CLAB Central Line Associated Bacteraemia DNA Did Not Attend ED Emergency Department ESPI Elective Services Patient Flow Indicator FTE Full Time Equivalent FSA First Specialist Assessment LMC Lead Maternity Carer MCIS Maternity Clinical Information System MoH Ministry of Health MSC Manukau SuperClinic SRO Senior Responsible Officer WIES Weighted Inlier Equivalent Separations YTD Year to date Service Overview

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

Activity summary For May 2017, discharges in Kidz First Medical were up by 25 on the previous May, so close to usual pattern. ED presentations were 40 less for the month. YTD both WIES and discharges continue to be lower due to the very unusual winter months and lower than usual volumes over January and February. Inpatient admissions have resulted in 2017 fewer presentations to ED and 434 fewer admissions YTD. We have however, seen a marked increase in both presentations to ED and inpatient admissions since the beginning of June. ED volumes have been an average of 100 children per day which is usually the pattern in the height of winter. Neonatal Unit The Neonatal Unit has continued with both higher acuity and admissions. Whilst the actual number of discharges from the Unit is up 14% (41 babies), the WIES is up 53% (499) reflecting that increase in acuity. Occupancy for May was 98% with a few days more than 30 out of our 38 physical cots being occupied. We have therefore already needed to increase both the nursing ratios through the nursing bureau or nurses redeployed from Kidz First Wards as well as increase the number of average resourced cots to 30. Recruitment for additional nursing staff is underway. Births There were 533 births at Middlemore Hospital and 58 at the three community units; a total of 591 births for the month which is 45 births less than May 2016. YTD, the overall birth numbers are 6,721 which is 22 births less than same period last year. The births at the three Community Units are still

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slightly behind, 37 down on last year hence the pressure remaining on maternity services at Middlemore Hospital. Emerging Issues

Caesarean Section Guideline Following a serious adverse event and the recommendation to “develop a guideline on the classification and communication of caesarean section to ensure the principles of multi-disciplinary communication underpin the smooth, safe and rapid transition to delivery”, a guideline entitled ‘Categorisation of Urgency for Caesarean Sections and How to Arrange the Procedure’ has been developed. This guideline is designed to provide health professionals with information and recommendations regarding the various categories for urgency of caesarean section including information on how to make appropriate arrangements at Middlemore Hospital. CM Health has adopted the four-grade classification system for urgency of caesarean section in accordance with The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. The guideline was rolled out on 1 May and communicated with staff across the weeks prior. Corrective Action – Vitamin K for newborn babies Work has now been completed following a certification corrective action regarding the prescribing of Vitamin K for all newborn babies. The revised Immediate Postnatal History and Examination form with the Stat Vitamin K prescription template, to meet the legal requirements of a prescription, has been finalised and the new forms were made available on Oracle in May in preparation for implementation of the new forms on 1 June 2017. Update on previously reported issues


Neonatal Unit capacity

Apr 2016 Occupancy remains high after some easing over Christmas and New Year 2017. A project manager has been appointed for the regional capacity work. The first draft of this report will be presented to the regional CD and GM forum in May 2017. However, we have simultaneously commenced a nursing recruitment and model of care project to support more junior nursing staff to work in the neonatal specialty.

Caesarean Section Rate

8 Mar 2017 The caesarean section rate for May was 30%. YTD rate is 26% against 23% last year. The caesarean section rate and processes are reviewed routinely with the clinical team.

Midwifery workforce

8 Mar 2017 • Sixteen new graduate employed midwives and 11 new graduate LMC midwives started on 1 May 2017.

• A very successful powhiri was held on 2 May 2017. • Orientation for all staff took place during May. Each new

graduate midwife was assigned a preceptor(s) and feedback has been good about the level of support the new graduates are receiving.

• We are awaiting feedback from the previously (April) reported national workstreams and meetings.

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Response to Action Item Actions previously assigned by the Hospital Advisory Committee are reported back on in this section. HAC Meeting 31.5.2017 – MCIS “Provide an update on the status of MCIS following the meeting on 26 May”. National Governance Group meeting overview The National Governance Group met on Friday 26 May. The focus of this meeting was changed for the group to comment and agree on a set of recommendations to the MoH SRO for MCIS (Jill Lane) rather than reviewing an options paper and evaluation report from Deloitte. The evaluation report had not been completed and verbal feedback on the key themes from interviews with maternity staff only was provided at the meeting. All recommendations were debated rigourously with agreement on:

• Continuation of a national maternity information system led by MoH. • MoH to continue to fund the development of the current MCIS (BadgerNet) so that the

system could be 'fit for purpose' with a clear roadmap and timeframe for further releases. • MoH not to roll out the current system to other DHBs until the early adopter DHBs and

national Governance Groups are in agreement that the system is ready for roll out. From this meeting the MoH Project Manager will now amend the recommendations for presentation to the SRO on 19 June (delayed from initial timeframe). No date was confirmed for a final decision. CM Health MCIS status update • Version13 was released on 9 May. Some minor release issues were identified and resolved.

Version 13 does provide improvement for the two high priority clinical workflow issues but as mentioned above significantly more development is required for all clinical workflow issues to be resolved.

• Standardisation of MCIS for CM Health is progressing well with a Business Analyst working with the MCIS Clinical Midwife Specialist and Clinical Leaders.

• First extended hybrid ‘lab’ session took place on 24 May with a further session planned on 6 June. From the first session it looks unlikely that an extended hybrid (i.e. introducing more clinical records on paper in conjunction with MCIS) will increase clinical safety.

• The CM Health MCIS Steering Group has prepared a letter for the CEO to send to the MoH Director General expressing concern about the lack of progress on the roadmap, timeframes, and funding to develop the MCIS into a clinically ‘fit for purpose’ system.

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Trend Rating Commentary (by exception)FY16-17^ May-17 Target Var Actual Target Var

Acute Caseweight - Gynaecology Inpatients- acute 154 138 12% 1490 1517 -2% Small variance on last year

Acute Caseweight - Secondary Neonatal Womens health 118 148 -20% 1376 1631 -16%More babies required to stay in Neonatal Unit, offset by increase in secondary WIES

Acute Caseweight - Inpatient maternity care primary maternity facility 314 379 -17% 4039 4166 -3%offset by increase in Secondary WIES, Small Variances

Acute Caseweight - Women's Health secondary 590 537 10% 6344 5905 7% Increase in C-section and acuity

Elective Caseweight - Gynaecology Inpatients - elective 122 131 -7% 1228 1441 -15%Year to Date impacts of lower # of procedures / theatre list due to larger size patients as well as increase in hysteroscopies.

Hysteroscopy 11 N/A N/A 116 N/A N/A New PUC from July 2016Total Discharges - Gynaecology Inpatients- acute 270 272 -1% 2789 2977 -6% Small varianceTotal Discharges - Secondary Neonatal Womens health 179 166 8% 1743 1724 1%

Total Discharges - Inpatient maternity care primary maternity facility 306 335 -9% 3530 3406 4%Good utilisation of primary units for transfers from Middlemore

Total Discharges - Women's Health secondary 1207 1314 -8% 13131 13043 1%Total Discharges - Gynaecology Inpatients - elective 131 161 -19% 1305 1470 -11% As per the aboveGynaecology - 1st Attendance 284 218 30% 2654 2667 0% Offset by increase in Virtual FSANon-Contact FSA Gynae Virtual 27 33 -18% 524 368 42%First Obstetric Consults S/B Doctors 280 256 9% 2740 2819 -3% Small Variances, but increase in Virtual FSADHB non-specialist antenatal consults 1293 1603 -19% 12940 17635 -27% MCIS / iPIMS data issues, volume understatedGynaecology - Subsequent Attendance 368 291 26% 2817 2683 5%Subsequent Obstetric Consults F/U S/B Doctors 268 305 -12% 2471 3356 -26% Better coordination requiring less follow upsDHB non-specialist postnatal consults 1120 1727 -35% 11,820 18993 -38% MCIS / iPIMS data issues, volume understatedBudgeted FTEs 365 338 -8% 346 338 -2% High OT, High Sick leave due to MW VacanciesOperating Costs ($000) $417 $400 -4% $4,689 $4,407 -6%Personnel Costs ($000) $3,053 $2,873 -6% $32,171 $30,598 -5%Financial Result Total ($000) $3,289 $3,155 -4% $34,775 $33,695 -3%Reduce Clinical Outsourcing ($000) $10 $6 -67% $156 $65 -140% Offset against additional revenues

Trend Rating Commentary (by exception)FY16-17^ Apr-17 Target Var Actual Target Var

% Staff with Annual Leave > 2 years - (one month in arrear) 20.2% 5.0% -15.2% 22.0% 5.0% -17.0%% Staff Turnover - (one month in arrear) 13.3% 10.0% -3.3% 12.4% 10.0% -2.4%% Sick leave - (one month in arrears) 4.2% 2.8% -1.4% 3.4% 2.8% -0.6%Workplace injuries recorded per 1,000,000 hours - (one months in arrears) 0.00 10.5 10.5 8.8 10.5 1.7


Emergency trolley checks (days checked) per month 92% 100% -8% N/A N/A N/AHand hygiene (compliance with checks) per month 90% 80% 10% N/A N/A N/ASafe Sleep audits completed 98% 100% -2% N/A N/A N/A Pleasing progress being made

Violence Intervention Programme (VIP) Screening 66% 80% -14% N/A N/A N/ARolling out new programme gradually. Rates improving

Monitoring Trend

WOMEN'S HEALTH SCORECARD May 2017En

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ED 6 hour target - National Health target (Gynae) 87% 95% -8% 93% 95% -2% Reviewing process in ECESPI 2 - No. waiting >4 months for FSA - Elective 0.0 0.0 0.0 0.0 0.0 0.0ESPI 5 - No. waiting > 4 months for treatment - Elective 0.0 0.0 0.0 0.0 0.0 0.0


% transcribed clinic letters authorised <7 days created 85% 95% -10% 87% 95% -8%

ALOS Women's Health - babies (WNB and Neonates) 3.20 3.10 -0.10 3.30 3.80 0.50Shorter LOS as more babies required to stay longer in NNU

Average Length of Stay Gynaecology - Middlemore 1.83 1.96 0.13 1.58 1.60 0.02Average Length of Stay Gynaecology - MSC Inpatients 0.81 0.68 -0.13 0.71 0.76 0.05Average Length of Stay Obstetric (DHB Mat) (1 month in arrear) 2.16 2.47 -0.31 2.31 2.17 0.14Average Length of Stay Obstetric (Ind. Mat) (1 month in arrear) 2.21 2.08 0.13 2.20 2.08 0.12Average Length of Stay Vaginal Deliveries overall 2.33 2.03 0.30 2.04 2.10 -0.06 Small variance

Maaori - 1st time mothers 2.62 2.10 1.21 2.53 2.62 -0.09 Small variancePacific - 1st time mothers 4.23 3.03 1.20 2.75 2.56 0.19


FSA / Follow up ratio - Gynae 1:1.30 1:1.1 1:1.06 1:1DNA - Midwifery Antenatal clinics - First 13% 15% 2% 14% 13% -1% Small variancesDNA - Midwifery Antenatal clinic - Follow up 12% 15% 3% 13% 15% 2%DNA - Doctor Antenatal clinics- FSA 13% 15% 2% 13% 12% -1% Small variancesDNA - Doctor Antenatal clinics - Follow up 11% 7% -4% 11% 18% 7% Good improvement YTD

Trend Rating Commentary (by exception)FY16-17^ May-17 Target Var Actual YTD* Var

Outpatient DNA - Maaori (Gynae) 14% 13% -1% 13% 10% -3%Outpatient DNA - Pacific (Gynae) 15% 13% -2% 10% 10% 0%Outpatient DNA - Maaori (Obst) 21% 23% 2% 24% 10% -14%Outpatient DNA - Pacific (Obst) 15% 16% 1% 17% 10% -7%


Patient experience survey - month (n=40) and YTD (n=591) 85% 76% 9% 77% 76% 1%

NOTES^FY16-17 - fiscal year 2016 and fiscal year 2017

Improving on previous year actuals

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Acute Caseweight - Paediatric Medicine Inpatients 252 267 -6% 2617 3006 -13%Unusual winter and Summer, May similar to last year

Acute Caseweight - Emergency Medicine - ED 78 75 4% 751 746 1%Unusual winter and Summer, May similar to last year

Acute Caseweight - Inpatient Paediatric ICU 2 3 -33% 76 29 162% 1 Burn Patient collected 54 WIESAcute Caseweight -Secondary Neonatal Unit 151 116 30% 1773 1274 39% High acuity and high volumeAcute Caseweight - Paed Surg - accounted under Adult Surgery 213 172 24% 1797 1876 -4% Slight decreaseElective Caseweight - Paed Surg - accounted under Adult Surgery 92 75 23% 871 750 16% Increasing trend and high acuity

Total Discharges - Paediatric Medicine Inpatients 469 443 6% 4652 5077 -8%Unusual winter and Summer, May similar to last year

Total Discharges - Emergency Medicine - ED 273 248 10% 2762 2736 1% Discharges up on last yearTotal Discharges - Inpatient Paediatric ICU 1 1 0% 23 18 28% On trackTotal Discharges - Secondary Neonatal Unit 32 30 7% 340 299 14% High acuity and high volumeTotal Discharges- Acute Paed Surg - accounted under Adult Surgery 191 165 16% 1818 2010 -10% Lower discharges but higher acuity YTDTotal Discharges- Elective Paed Surg - accounted under Adult Surgery 156 197 -21% 1335 1560 -14% Lower discharges but higher acuity YTD

ED attendances 2003 2043 -2% 21913 23930 -8%Unusual winter and Summer, May similar to last year

Paed Medicine - 1st Attendance 232 180 29% 2052 1937 6% Increase on last yearNon-Contact FSA - Any Medical specialty 37 42 -12% 539 458 18% On track Paed Medicine - Subsequent Attendance 314 322 -2% 3214 3378 -5% Focus on FSAs

Budgeted FTEs 293 272 -8% 273 274 0%Good AL mgmt over Xmas and New year in addition to Vacancies

Operating Costs ($000) $329 $257 -28% $3,791 $2,780 -36%Additional costs offset against additional revenues (i.e. Gateway, MM Clinical Trials).

Personnel Costs ($000) $2,492 $2,439 -2% $26,204 $26,000 -1% offset by additional revenueFinancial Result Total ($000) $2,458 $2,513 2% $26,430 $26,715 1%Reduce Clinical Outsourcing ($000) $13 $4 -225% $68 $50 -36% Offset by additional revenue

Trend Rating Commentary (by exception)FY16-17^ Apr-17 Target Var Actual Target Var

% Staff with Annual Leave > 2 years - (one month in arrear) 16.7% 5.0% -11.7% 19.4% 5.0% -14.4% Trend is decreasing% Staff Turnover - (one month in arrear) 13.0% 10.0% -3.0% 15.9% 10.0% -5.9% Monitoring trend% Sick leave - (one month in arrears) 3.3% 2.8% -0.5% 3.4% 2.8% -0.6% Monitoring trendWorkplace injuries recorded per 1,000,000 hours - (one months in arrears) 0.0 10.5 10.5 11.3 10.5 -0.8 No concerns identified

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Neonatal Rate of medication errors/1000 bed days per month 3.6% 3.2% -0.4% 3.5% 3.2% -0.3% Very small varianceNeonatal Care CLAB rate per 1000 line days per month 0.0 0.0 0.0 N/A N/A N/ACLAB insertion bundle compliance - NNU 100% 100% 0% 97% 100% -3% Increasing compliance

CLAB prevention maintenance bundle compliance- NNU 90% 100% -10% 88% 100% -12%Process is followed 100% - documentation of the process not always completed.

Emergency trolley checks (compliance with checking) 92% 100% -8% N/A N/A N/AHand hygiene (compliance with checking) 90% 80% 10% N/A N/A N/A

Safe sleep - audits completed 82% 100% -18% N/A N/A N/ANeonatal unit is completing audits but due to very high acuity and volume there is not always the opportunity to provide education to parents

Violence Intervention Programme (VIP) Screening 76% 80% -4% N/A N/A N/ANew programme rolling out gradually. Rate steadily improving


ED 6 hour target - National Health target (Kidz First EC) - Initial speciality 97% 95% 2% 98% 95% 3%Nurse Led discharges (in process of formulating KPI)ESPI 2 - No. waiting >4 months for FSA - Elective 0.0 0.0 0.0 0.0 0.0 0.0


% transcribed clinic letters authorised >7 days of created 79% 75% 4% 79% 75% 4%Trend Rating Commentary (by exception)

FY16-17^ May-17 LY Act Var Actual YTD* VarAdmission Rate Babies in the first year of life (Total) 21% 23% 2% 21% 23% 2%

Admission Rate Babies in the first year of life (Maaori) 25% 28% 3% 25% 27% 2%Admission Rate Babies in the first year of life (Pacific) 29% 33% 4% 28% 30% 2%

ALOS (raw)- Kidz First - Surgical - Surgical Floor 2.25 1.75 -0.50 2.12 2.05 -0.07 Small varianceALOS (raw)- Kidz First Medicine - KF Wards 2.65 2.62 -0.03 2.66 2.69 0.03ALOS (raw)- Kidz First Medicine - EC Short Stay (hrs) 4.18 4.52 0.34 4.28 4.59 0.31ALOS (raw) - Kidz First - Neonatal 18.7 18.4 -0.3 21.1 17.9 -3.2 High acuity


Outpatient DNA - FSA 7% 13% 6% 8% 10% 2%Outpatient DNA - Follow up 11% 11% 0% 12% 12% 0%


Patient experience survey - month (n=6) and YTD (n=102) 67% 76% -9% 71% 76% -5%Responses remain very low. Investigating strategies to roll out IPad consistently

NOTESLY Act - Last year actuals^FY16-17 - fiscal year 2016 and fiscal year 2017

Reflecting lower admissions

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Adult Rehabilitation and Health of Older People Glossary

ACC Accident Compensation Corporation ARRC Age-Related Residential Care AT&R Assessment, Treatment and Rehabilitation ED Emergency Department FTE Full Time Equivalent GP General Practitioner/General Practice HBSS Home Based Support Services LOS Length of Stay MMH Middlemore Hospital YTD Year to date Service Overview

The Adult Rehabilitation and Health of Older People Division is managed by Dana Ralph-Smith (General Manager) with Dr Peter Gow (Clinical Director) and Lyn Cooper (Clinical Nurse Director). In addition, to support the Health of Older People contracted services Dr Kathy Peri is Clinical Nurse Director. Highlights

Stroke Service The whole-of-system Stroke Service at CM Health, and in particular the new integrated stroke team, have been working on documenting patient journey pathways from acute to community, and identifying where improvements can be implemented and tested to improve patient quality, safety and experience. Recruitment of nursing allied health and medical resources to meet acute services in particular has continued. Specialised Rehabilitation Services The Specialised Rehabilitation Services at CM Health continue to work with their regional clinical and managerial colleagues to plan the delivery of rehabilitation services across the continuum of care, including Rehabilitation services for Spinal Stroke Amputee Rehabilitation General and Multi-trauma. Emerging issues

Safe Moving and Manual Handling Occupational Health and Safety Services have established a relationship with the Waitemata DHB Moving and Handling Consultant, Anne McMahon, who has been very helpful in giving initial guidance on the data and research that is currently available in New Zealand. Anne presented to the Safe Moving and Manual Handling Sub-committee on 22 May 2017, and ACC presented on 6 June 2017. Using information and advice from these subject matter experts, the Safe Moving and Manual Handling Steering group has commenced gathering the necessary information to inform a business case outlining the options for funding to manage the training and risk assessment roll out of safe moving and manual handling across CM Health.

068



Spinal Inpatient ACC Revenue ('000s) $531 $534 -0.7% $7,054 $6,253 12.8%Non-acute Rehabilitation ACC Revenue ('000s) $687 $348 97.2% $5,638 $4,360 29.3%Budgeted FTEs 492 480 -2.5% 462 475 2.6%Operating Costs ($000) $4,032 $4,139 2.6% $43,608 $43,949 0.8%Personnel Costs ($000) $3,135 $3,313 5.4% $33,322 $34,945 4.6%Financial Result Total ($000) $3,474 $3,520 1.3% $36,612 $37,000 1.1%

Reduce clinical outsourcing ($000) $236 $263 10.4% $3,282 $2,895 -13.3%

There has been an increase of 83 clients from June '16 upto January '17 this increase has occurred to allow patients early supported discharge back into communities. Analysis being undertaken to identify opportunities to make further efficiencies


% Staff with Annual Leave > 2 years 4.4% 5.0% 0.6% 4.4% 5.0% 0.6%% Staff Turnover 15.5% 10.0% -5.5% 14.9% 10.0% -4.9% Retirements and promotions% Sick Leave 3.6% 2.8% -0.8% 3.2% 2.8% -0.4% On track for year end

Workplace Injury per 1,000,000 hours 17.8 10.5 -7.3 16.1 10.5 -5.6Safe Moving and Manual Handling organisation wide being planned


Falls - % of falls assessments done in first 6 hours 100% 100% 0% 96% 100% -4%

Falls - % of Interventions completed 100% 100% 0% 97% 100% -3%Pressure Injuries - % of assessments done in first 6 hours 100% 100% 0% 96% 100% -4%Pressure Injuries - % of interventions completed 100% 100% 0% 100% 100% -1%Reduce over ride rate of Pyxis on AT&R wards decrease medication errors to 15% 14% 15% 1% 14% 15% 1%


Access to specialist services -volumes of Geriatric AT&R Hotline Calls 37 36 1 30 36 -6 We contiune to promote the hotline to GPs and ARRC


Maintain number of patient 75’s or older LOS > 10 days in AT&R wards 52 54 2 50 54 4Maintain direct admissions from GPs to ATR wards 18 23 5 23 23 0Avoidable presentations to ED from Aged Residential Care Facilities (ARRC) 13 15 2 8 15 7.3MMH % patients discharged to discharge lounge or home by 1100hrs 32% 32% 0% 30% 32% -2% System wide focus on improving performanceRehabilitation 7 day Readmissions rate 3.4% 2.9% -0.5% 2.5% 2.9% 0.4%Acute Readmission within 28 days - Total for Rehabilitation beds (1 month in arrears)

10% 11% 1% 9% 11% 2%

We continue to meet with Charge Nurse Managers to discuss opportunities for improvement

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Trend Rating Commentary (by exception)

FY16-17 Apr-17 Target Var Actual Target Var% +65years with long term HBSS - comprehensive clinical assessment & care plan 95% 75% 20% 94% 75% 19%


Number of Spinal Rehabilitation Outreach Clinic days 5 4 1 58 30 28


% of patients who rated service as very good or excellent 84% 90% -6% 78% 90% -12%Performance is based on number of patients rating service 'very good' or 'excellent'. Only one of a total 25 respondetns rated poor or fair, remaining were good.

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Mental Health and Addictions Glossary

AOD Alcohol and Other Drugs FTE Full Time Equivalent HDU High Dependency Unit (Intensive Care) LDU Low Dependency Unit (though not low level care, as admission threshold is high) LOS Length of Stay MH Mental Health MoH Ministry of Health NGO Non Government Organisation PRIMHD Programme for the Integration of Mental Health Data Service Overview

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

New Acute Mental Health Unit Notable visual progress can be seen onsite with timber and steelwork progressing across a significant part of the site. Key progress milestones are:

• HDU bedrooms roof framing completed • LDU prefabricated bedroom wall frames erected • LDU/HDU staff area slab 30% complete • LDU socialisation area steelwork near complete • Lift pit dewatered and waterproofing laid.

Overall, progress remains behind schedule however there has been encouraging progress reported over the period by the independent programmer. A review of the expected completion date will be made at the end of June to inform recruitment of new staff for the increased six beds, which will become available on the completion of stage one of the building programme.

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Update on previously reported issues

There are no previously reported issues which have not been resolved.

Response to Action Item Actions previously assigned by the Hospital Advisory Committee are reported back on in this section. HAC Meeting 31.5.2017 – Acute Psychiatry “Peter Watson confirmed the service is currently facing some technological issues in measuring some of the triage data accurately and is currently undertaking an audit to ensure the data is being measured correctly. He agreed to come back with a proposal to provide a regular report to the Committee once the audit is completed”.

The Division is awaiting the outcome of the audit. This has become a ‘chart review’ exercise in the first instance given the complexities of the triage and intake process. Once the audit results are available, proposed monitoring measures will be presented to the Committee.

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Overtime costs ($000) $170 $149 -14.3% $1,907 $1,638 -16.4% High acute demand off-set by community vacanciesBudgeted FTEs 659 689 4.3% 650 689 5.7% Does not include locum FTEsOperating Costs ($000) $6,133 $6,065 -1.1% $63,012 $62,942 -0.1%Personnel Costs ($000) $5,429 $5,758 5.7% $56,195 $59,558 5.6%Financial Result Total ($000) $6,026 $6,046 0.3% $62,439 $62,729 0.5%


% Staff with Annual Leave > 2 years8.9% 5.0% -3.9% 9.1% 5.0% -4.1%

Managers are working with staff on individual plans to reduce annual leave balances

% Staff Turnover 10.8% 10.0% -0.8% 10.6% 10.0% -0.6%% Sick Leave

4.2% 2.8% -1.4% 3.7% 2.8% -0.9%Sick leave reviews undertaken with staff with high sick leave

Workplace Injury Per 1,000,000 hours 0.0 10.5 10.5 9.6 10.5 0.9


Number of Seclusion events/100,000 6.4 5.0 -1.4 N/A N/A N/A

Seclusion hours/100,000 84 50 -34 N/A N/A N/ANumber of Clients Secluded/100,000 2.9 3.0 0.1 N/A N/A N/A


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

0-19 years 75% 80% -5.2% N/A N/A N/A Unique Clients seen has exceeded MoH Target by 105720-64 years 86% 80% 6.0% N/A N/A N/A65+ years 92% 80% 12.1% N/A N/A N/A

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

0-19 years 95% 95% 0.0% N/A N/A N/A Unique Clients seen has exceeded MoH Target by 105720-64 years 98% 95% 2.7% N/A N/A N/A65+ years 98% 95% 2.7% N/A N/A N/A


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

0-19 years 3.8% 3.2% 0.7% N/A N/A N/A20-64 years 3.8% 3.2% 0.6% N/A N/A N/A65+ years 2.4% 2.6% -0.2% N/A N/A N/A Meeting the wait time targets - no build-up of a waitlist

Readmissions to Tiaho Mai within 28 days - Total (1 month in arrears) 7.6% 12.0% 4.5% 8.9% 12.0% 3.1%

MENTAL HEALTH SCORECARD May 2017En

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Inpatient Occupancy - Tiaho Mai Acute Mental Health Unit 95% 85% -10.4% 96% 85% -11.0% Signifies overcrowdingNumber of Tiaho Mai Inpatient LOS >35 days 8 10 2.0 9 10 0.6


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

0-19 years 5.7% 4.5% 1.2% N/A N/A N/A20-64 years 8.6% 7.7% 0.9% N/A N/A N/A65+ years 2.9% 2.6% 0.3% N/A N/A N/A

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Facilities Glossary

KA2 Ko Awatea II MSC Manukau SuperClinic WoF Warrant of Fitness Service Overview

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

Ko Awatea II – Construction Contract The division’s Capital Works function is engaged in a handover of the KA2 Project reviewing the project execution plan and seeking integrate the KA2 Project within facilities project delivery portfolio. The KA2 team and corporate finance functions are working jointly to provide the Board with full summary of total project breakdown, including timeline, previously unaccounted for professional and fit-out costs, and transaction arrangements. This review once completed will provide the Board with requested assurances around the project delivery framework. The Capital Works team is further engaged in evaluating the repurposing of the facility and providing the Audit, Risk and Finance Committee with assurance that if the building is repurposed, what would be the best use, what costs would be incurred what design development would be required, and which walls/spaces would be redesigned and the associated engineering and space impacts. Asset Management Maturity Improvement Plan The division has sought to engage a project manager for the progression of the Treasury Investor Confidence review being undertaken in September 2017. A services commission offer has been made and accepted for phase one (only) of what will be a multi-phase project and comprises several specific investor confidence delivery activities outlined below:

1. Review background documents and meet with key stakeholders, 2. Development of the ‘strawman’ Criticality Matrix and review with key stakeholders, 3. Development of a method and approach to link Asset Criticality, Level of Service and Asset

Lifecycle Management, 4. Development of recommendations on how the above should be translated into

specifications for an Enterprise Asset Management system, 5. Development of a plan to implement the above, 6. Other activity as mutually agreed, and 7. Regular reporting on progress in project management software (Daptiv).

The project manager will also be in attendance at the Regional Asset Management Group to support the General Manager Facilities.

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Update on previously reported issues


Regional Water Supply – Potential for Contamination

19 Apr 2017 Facilities has recommended that due to the lack of redundancy in the Middlemore Hospital and MSC water supply infrastructure, as a minimum, CM Health retains drinking water at these facilities in case of a major event. Arrangements for this will be pursued.

Fatality involving Senior Engineer

31 May 2017 On the Night of the 3rd of May 2017 a Senior Engineer fell from the Galbraith Roof to his death. CM Health’s Health & Safety department has engaged an independent investigator who is leading an independent incident investigation and working with the Facilities team.

Devolved Property Management and Leasing

31 May 2017 In the past the negotiation of leases and maintenance of community based properties was managed directly by the occupying services. Facilities are engaging in centralising the control of the property assurance and negotiation process. External consultants have been brought in to review.

Asset Condition Survey 31 May 2017 Paper to be presented to July AR&F

IT Infrastructure Interface Management

31 May 2017 No change since previously reported.

Clinical Engineering Resources

31 May 2017 Clinical Engineering are working to return their WoF compliance rates to acceptable levels. Clinical Engineering are currently recruiting resources and working with Human Resources on a retention strategy. The insourced Clinical Engineering approach CM health has undertaken has proved to be an efficient and effective approach with good internal cost and operational controls. We are contracting externally to remediate the situation in the interim.

MSC Power Supply Failure

31 May 2017 Further to the loss of mains power supply to the Manukau Super Clinic, Vector has installed two new large capacity high voltage cables to the two transformers supplying the Manukau Super Clinic. The Engineering Department has undertaken an organised work program for the switching of Vector power supply loads. The temporary generator supply has now been removed. Phase two of the 2017 Manukau power supply resilience programme, required to upgrade the transformers has been approved.

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Middlemore Central Service Overview

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

Discharge Lounge At the last Committee meeting it was reported that a trial was underway to assess the value of opening the Discharge Lounge on Saturdays. This was found to be very beneficial in decanting the wards in a more timely way at the weekend, allowing flow from the Emergency Department. The Acute and Post-Acute Care nursing team take all their patients who have been identified as ‘Nurse Facilitated Discharges’ to the Discharge Lounge where they can finish the discharge process without blocking beds on the ward. The initiative will continue until the end of October. Discharge Lounge usage (Medical and Surgical wards):

Orderlies – technology pilot A pilot of software that uses smart-phones and Bluetooth technology has proved to be very successful for knowing where Orderlies are within the organisation, and being able to allocate tasks to the Orderly closest to the requester. Having demonstrated its benefit in time management, we are now ready to evaluate formally with a view to a further rollout for other uses e.g. tracking equipment such as wheelchairs within the organisation. New initiatives Middlemore Central has been leading, or involved with, a wide range of new initiatives across the hospital system. An overview of these is provided below. Winter Plan Volumes coming through the Emergency Department in May averaged 318 patients per day, peaking at 369 on 16 May. Additional beds have been staffed and resourced in both Ward 2 and Ward 31, with an additional bed on Wards 6, 7, 31 East, and 33 West.

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Bed Cleaning A working party has been established (membership includes Charge Nurses, Health Care Assistants, cleaning staff, and Ko Awatea Building Capability staff) to map and document a single standard approach to bed cleaning. A flowchart that clearly defines responsibilities and cleaning materials required for a routine discharge bed clean has been developed. The process is being trialled on Wards 8 and 9, where a Discharge Cleaner works between the two wards at the request of the Charge Nurses to ensure that there are no delays. Influenza Vaccination Although the official Flu Vaccination campaign has been completed by the Occupational Health & Safety team, Middlemore Central continues to provide the opportunity to vaccinate; all Duty Managers completed the vaccinators course prior to the start of the campaign. This allows staff working afterhours and at the weekend to come to a central point to receive their vaccination. This initiative has proved to be successful. Stranded Patient Workstream The Stranded Patient Workstream has been established with membership from Primary Care, Localities, and the Hospital, to identify the blockages of getting stranded (and sometimes complex) patients back into the community. Medicine and Surgery hold weekly multi-disciplinary team meetings to look at all patients with a length of stay greater than 10 days to ensure that there is a plan in place and it is being followed. Two workstreams are progressing, in line with the regional system level measures work underway:

1. Effective use of InterRAI 2. Improved flow of patients from the medical wards to AT&R.

We are also investigating how information relating to chronic care patients can be shared with the community to enable them to ‘in reach’ and assist in a supported discharge.

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6.1 Director of Patient Care, Chief Nurse & Allied Health Professions Officer

Prepared and submitted by Denise Kivell, Director of Nursing, on behalf of Jenny Parr, Director of Patient Care, Chief Nurse & Allied Health Professions Officer Summary Updates have been provided by the Directorate of Patient Care including Nursing, Midwifery and Allied Health in the hospital, and Primary and Integrated Care. Appendix 1 has been provided by the Undergraduate and Entry to Practice Development Lead, Ko Awatea and is in response to a question raised in a previous HAC meeting regarding Undergraduate Placements. ILC Conference and Summit, Uppsala University Hospital, Sweden The Director of Patient Care, Chief Nurse & Allied Health Professions Officer recently attended the annual 3-day ILC Conference and Summit, Uppsala University Hospital, Sweden and presented three components: 1 12 June 2017: Fundamentals of care and patient involvement: Latest research from around the

world. Title “Smiling is a Clinical Intervention” 2 13 June 2017: World café/forum. Title: “Patient and Whaanau Centred Care Standards

Programme, Elevating Quality Care Through Ward Leadership” 3 14 June 2017: Workshop, Reorganising clinical practice – “Involving the Patient Listening Event” http://intlearningcollab.org/wp-content/uploads/2017/05/ILC-2017_Conference-and-summit-program.pdf Karolinska Institutet and Karolinska University Hospital, Stockholm At the invitation of Yvonne Wengström - Professor and Director of Nursing Development Neurobiology Care Science and Society, the Director of Patient Care, Chief Nurse & Allied Health Professions Officer visited Karolinska University Hospital on 7 June 2017, to lead a seminar with senior nurses. Topic of the presentation was “Frontline Leadership – Panacea or Placebo for Improving Quality Care?” She was also able to have a guided tour of the New Karolinska Hospital which is currently being constructed. The new hospital changes the model of care to become centred around the flow of the patient. The construction also uses the latest design specifications and digital hospital principles. For additional information see http://www.karolinska.se/en/karolinska-university-hospital/news/2016/07/patients-new-healthcare-journey/ and https://www.youtube.com/watch?v=aJGmp_jskJ4&feature=youtu.be Workforce Nursing For May, there were 139 Full Time Equivalent (FTE) Nursing/Midwifery recruitable1 vacancies active with Recruitment. This reflects a 5% vacancy across the total workforce (Nursing, Midwifery and Health Care Assistant (HCA)). Of the open recruitment, 64 FTE were initiated in May.

1Positions becoming or currently vacant, which have been reviewed, and are advertised. This activity includes ongoing recruitment campaigns for ‘hard to fill’ areas, including attracting experienced nurses in Women’s Health, Mental Health (especially Child and Youth) and Emergency Department.

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http://intlearningcollab.org/wp-content/uploads/2017/05/ILC-2017_Conference-and-summit-program.pdf

http://intlearningcollab.org/wp-content/uploads/2017/05/ILC-2017_Conference-and-summit-program.pdf

http://www.karolinska.se/en/karolinska-university-hospital/news/2016/07/patients-new-healthcare-journey/

https://www.youtube.com/watch?v=aJGmp_jskJ4&feature=youtu.be


Of this total across Counties Manukau Health (CM Health) services, there are 10.7 FTE Senior Nursing roles, 3.8 FTE Enrolled Nurse (EN) roles, along with 85 FTE Registered Nurse (RN) vacancies (31 in community settings). There are 4.8 FTE Midwifery vacancies (inpatient and community). HCA recruitment is also high at 24.7 FTE HCA being recruited, 14.1 FTE to support community teams. (a) Nursing Workforce Hotspots

Mental Health has two key nursing leadership roles that are yet to progress in recruitment - Nurse Lead Pacific and Nurse Lead Maaori. These roles have a dual function of support service delivery, equity and of promoting mental health opportunities to undergraduates as these clinical transition experiences can encourage new graduate applications to mental health.

Ongoing campaigns to attract nurses to work at CM Health continue, particularly in Neonatal Unit, Midwifery, Mental Health, and Emergency Care. This includes a variety of approaches via usual recruitment, social media, and professional networks. Streamlining recruitment processes will be a key focus, with progress on moving Nurse Entry to Practice (NETP) candidates to permanent contracts, pooling of recruitment activity, and working closely with tertiary providers.

Additional winter cover nurses are being recruited across Medicine and for Kidz First wards; these roles will be used to help cover sick leave, additional patient acuity and volumes and maintain safety. In the Community, District Nursing has also reported high service demands due to capacity issues as a result of sick leave and high workloads.

(b) Nursing Pipeline and Education

The additional pre-winter intake of 24 NETP and the selection processes for the September 2017 intake of mid-year Bachelor of Nursing (BN) graduates have both commenced. On 15 June, there was a ceremony to mark the NETP completion for the May 2016 cohort. Eighteen of the 20 graduates have taken up roles across CM Health.

From September 2017, our new graduates will be employed on permanent contracts rather than fixed term contracts. This aligns with the region and also has additional benefits for retaining and reducing recruitment processes. Currently, retention rate is around 95%.

Funding for a further 10 NETP Maaori for the 2017/2018 financial year has been approved. The additional funding of $10,000 per nurse is a prioritisation by CM Health in conjunction with Health Workforce NZ and Maaori Development to support the employment of Maaori nurses into primary care practices. Primary Health Care Nurse Leaders are working collaboratively to determine how best to allocate the opportunities across Primary Care teams.

As part of the Health Equity campaigns, a collaboration between Manukau Institute of Technology (MIT) and CM Health is focussed on enhancing leadership activities of future Pacific Nurses, currently studying at MIT. Three CM Health leaders of Pacific descent (To’a Fereti, Aiva Kasimausi and Margie Apa) spoke to the students in May. The plan is to produce a short media piece in June, with script preparation underway. Remarkable student feedback has been collated from the sessions, and this will be the focus of the media piece.

The ANIVA Post Graduate Support Programme for Pacific nurses recently celebrated the inaugural Masters of Nursing Graduates in Wellington. Of the 12 graduates, 6 represented CM Health and a special acknowledgement was made by the Prime Minister to the ANIVA Programme and CM Health for their continued support of Pacific nursing.

ANIVA is the Samoan name for ‘the galaxy’ and it is viewed as a symbol of attainment through goal setting. Refer http://www.aniva.co.nz/about-aniva.html

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http://www.aniva.co.nz/about-aniva.html


Coaching and mentoring continues to be a fundamental component of the nursing leadership programme. Fourteen candidates commenced the current cohort on 22 May 2017. CM Health have developed a ‘coach the coaches’ programme to provide internal capability and sustainability. An evaluation of the programme has been successfully published in an international journal (June 2017). The full article can be viewed at https://doi.org/10.1108/LHS-07-2016-0030 The Advisory Board is an international body which provides education, research and networking. In May 2017 they provided a complimentary half-day on-site session for senior nurses and other professions on creating a culture of accountability, with a focus on fostering shared ownership of quality patient outcomes.

Midwifery PROMPT (Practical Obstetric Multi-Professional Training) is an evidence-based multi-professional training package for obstetric emergencies. It is associated with direct improvements in perinatal outcome and has been proven to improve knowledge, clinical skills and team working. Fifteen District Health Board and Lead Maternity Care midwives attended a PROMPT workshop at Pukekohe Birthing Unit on 23 May 2017. This workshop provided the midwives with the opportunity to practice emergency scenarios such as postpartum haemorrhage, prolapsed cord, cardio-pulmonary resuscitation and shoulder dystocia in a rural primary setting. Allied Health Currently, workforce concerns for occupational therapists are in Mental Health where recruitment is underway for 9 FTE positions. Two teams have no Occupational Therapists and one other team lacks Occupational Therapy experience. The Mental Health Associate Professional Leader role has been filled via secondment for the next four months and will provide some much needed additional support to mental health recruitment. The Kidz First Child development community team are now fully staffed for Occupational Therapy and have successfully managed to reduce the Occupational Therapy waitlist from 176 to 97. The Health Equity campaign project “Diversifying the Allied Health Workforce” has an upcoming presentation (July) to South Auckland school career advisors to inform and encourage them to support Maaori and Pacific students to develop an interest in Allied Health, Scientific and Technical roles as a career choice. A Career and Salary Progression (CASP) objective recently submitted identified a workload and case complexity measurement tool to assist community paediatric dieticians. Results identified an increasing case load, greater than that supported by other services in the Auckland Region. Work is underway to evaluate strategies to ensure safe workloads are maintained. The Allied Health Educator role (0.5 FTE, fixed term of 12 months) has been appointed to coordinate and facilitate professional development activities for the Allied Health, Scientific and Technical workforce. The appointee has joined the Inter-professional Education Team within Building Capability (Ko Awatea) and will maintain close working relationships across the Allied Health, Scientific and Technical workforce. Continued progress towards improved staffing levels for physiotherapy is being made; the only areas of concern remaining are Home Health Care and Kidz First Community Development. There are programmes in place to address these areas of concern.

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https://doi.org/10.1108/LHS-07-2016-0030

https://doi.org/10.1108/LHS-07-2016-0030


Patient Experience Nursing Understanding “what matters to you?” is important in terms of our organisation’s values and our everyday interactions with patients, whaanau and staff. The “What Matters to You?” day was celebrated on 24 May and is a concept which started in Norway in 2014, with the aim of encouraging and supporting more meaningful conversations between people who provide and receive health and social care services. We know that the effect of focusing on ‘what really matters to people’ can lead to improved care and reduced waste. This approach is viewed positively by people who both give and receive care and support. For the third year, CM Health registered with Healthcare Improvement Scotland, which promotes this growing international movement. In late May, we encouraged as many people as possible to have a ‘What Matters to You?’ conversation with colleagues, patients, and whaanau. This information was collated and analysed to identify themes, and has been shared at a number of forums, including Grand Round. Allied Health Patient Experience surveys are consistently telling us that the Foodservice in CM Health needs improvement. To improve communication between the Foodservice provider and CM Health, there is a recurring monthly meeting. However the structure has been changed to ensure that all actions that are resultant from staff or patient feedback have been captured and actioned in the best possible way. Inpatient Experience Report Retaining the theme of communication, we have worked with Cemplicity to develop a service level dashboard which will provide staff with more meaningful information. This month’s focus is Medicine and Rehabilitation services. Efforts to boost participation and email collection for both the National Survey and Inpatient survey continue, with email collection by area being monitored. Volunteer Services The Rainbow Volunteers (based on the Middlemore Hospital site) were runners-up in the recently announced 2017 MoH Volunteers Awards in the Healthcare Provider Service Volunteer team category. Jo Rankine, the acting Volunteer Manager, accepted the award on behalf of CM Health and the volunteers. (a) The Manukau Super Clinic Shuttle Service

The Shuttle Service was temporarily put on hold in March 2017 while we ensured our volunteer drivers completed necessary police, health and safety and licencing checks in line with recent changes to legislative requirements. All clear police vetting results have been received to date and the volunteers have received the necessary training and health and safety clearance. Accordingly, the Northern shuttle service will resume on 10 July with plans to resume the Southern timetable as volunteer numbers permit.

(b) The Manukau Super Clinic Mailroom

The sending of clinic letters to patients has been entirely dependent on the volunteer workforce. However, with a recent decline in the volunteer numbers at MSC alternative options are being explored to ensure the longer term sustainability of this service. The immediate risk is being managed within existing resources and a business plan for the longer term management is being considered.

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Quality and Improvement Nursing Hospital services continue to experience a busy early arrival of winter, with very full wards and complexity of patients in all services. Action on a number of fronts with clinical staff and support services continues to ensure efficient patient journeys, timely discharges, lower re-admissions, and coordination with community services and colleagues. Middlemore Central continues to convene a number of daily operational meetings and support efficient flow with community services represented, along with Charge Nurse Managers and Duty Managers. Saturday opening of the discharge lounge is underway, to assist with the winter flow and capacity issues. Ward teams are focused on prompt transfers from Emergency Care, use of Goal Discharge Dates, discharging before 1100 and working with Allied Health staff to prioritise patients due for discharge. New electronic whiteboards will support all these processes. (a) e-Vitals Clinical Documentation Programme (the recording of vital signs on a mobile device)

A conference abstract will be presented at the Nursing Informatics conference in November as a case study of nurses in the early adopter wards going from ‘paper heavy’ to ‘paper light’ ways of working. The two test ward environments will Go Live on 21 August for a test period of 8 weeks, prior to an extensive rollout.

(b) Care Capacity Demand Management (CCDM)

A number of implementation challenges with embedding the system are being addressed, to ensure data is accurate and that it is interpreted correctly. The Steering Group is preparing for a visit by the National Safe Staffing/Healthy Workplace Unit in July, as part of system validation and closely linked to colleagues at Waikato. The CCDM coordinator is working with ward staff on process expectations and collecting fully reflective data. Baseline operational data for a number of sources will be used in validation and evaluation.

Midwifery (a) Young Mums (Teenage/Child Pregnancy) Process Guide and Resource Folder for Community

Midwives A process guide and resource folder on teenage/child pregnancy developed by the Community Midwives, this guide includes care processes, decision making tools, guides and templates. Linkages are made with Oranga Tamariki (previously Child, Youth and Family Services). Guidance on privacy is woven through the content.

(b) Process Guide for the Delivery of Midwifery Care for Women and Babies Residing in Known Gang

Houses/Clubhouses A process guide covering the delivery of midwifery care for women and babies residing in known gang houses/clubhouses was endorsed and implemented in May to ensure that vulnerable women and babies are still able to access midwifery care, while keeping members of staff safe in their daily working environment within the community. This forms part of the Community Midwifery Services on-going work to ensure safe working practices while delivering DHB services within the community setting.

(c) Secure Email Links Established

Secure email links established between the DHB and Plunket (Nationally) and the DHB and Family Start Mangere will enable CM Health to discontinue unreliable and difficult to trace, sometimes unreadable faxing of referrals and patient information. Further work is focussed on the timeliness of patient referrals, adhering to confidentiality and privacy guidelines.

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(d) Living Our Values Maternity North and South Project This project commenced in December 2016 with the goals of improving inpatient care experience, decreasing maternity process variation, standardising clinical pathways of care and improving staff satisfaction. A range of solutions have been proposed including a physical division of North and South wards, leadership realignment, standardised pathways to reduce variation and a further focus on the needs of mothers and babies in relation to improved experience. Additionally, there are solutions proposed to evaluate workload, acuity, patient flow and a strategy to improve the times at which discharge occurs.

Allied Health The Occupational Therapy Supervision audit report has been completed with a variety of improvements suggested, including the development of a database of available supervisors and their profiles. This initiative will be expanded over time to include other disciplines to support inter-professional supervision. Whilst progress has been made toward developing the Physiotherapy First Specialist Assessment roles for the management and treatment of shoulder injuries, this is temporarily paused due to the Physiotherapist being on sabbatical. Work continues on the development of an Allied Health dashboard and scorecard comparable to Waitemata DHB’s. The dashboard will provide Allied Health a clear updated view of the workforce data and maintenance of credentialing expectations, such as annual practicing certificates and compulsory training/education. A review of after-hours and weekend social work service in the emergency department indicates that the current levels are sufficient for meeting the demand for social work interventions. The Community Women’s Health Midwifery/Social Work integration project has been completed. Interim recommendations focus on establishing improved working relationships with Family Start, including their understanding of CM Health’s pathway for high risk unborn children and their mothers, together with establishing a secure information sharing system. There are two research projects underway in collaboration with The University of Auckland (UoA), for assessment and treatment of dysphagia (difficulty in swallowing) secondary to spinal injury. One of these projects will scope service efficacy for dysphagia rehabilitation and may result in a business case around this in the near future. Currently, speech language therapy is contracted into the Intensive Care and High Dependency Units for fibre-endoscopic evaluation of swallowing, in the early stage of a patient with spinal injury. Note, this is not provided for rehabilitation purposes. Plan of Care Following a visit to Waitemata DHB on 23 June to view their variance care plan and gain feedback from its users, and subsequent discussion at the CM Health Plan of Care Working Group meeting on 29 June, the draft plan of care forms are being refined. Testing is due to begin on the two wards on 10 July 2017. Safety, Experience, Certification, Measurement Operational Group (SECMOG) The Group is facilitating information required for the review of measurement and integrated reporting of the quality of patient care scoping exercise that is currently underway. This scoping links to the issues identified with some of the databases that contribute to the collection of quality of care data and the risk assessment that was submitted highlighting the contributing factors for action as required.

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Falls Prevention The following plan-do-study-act (PDSA) tests are underway to look at improving post falls review and documentation. 1 A post-fall huddle analysis template and process is being tested on Ward 24 (geriatric

rehabilitation) during May/June. The falls huddle is to include Charge Nurse Manager, key nurse, allied health, medical representative (if available), and a member of the Falls Prevention Group or quality representative. The intention of the huddle is to review the circumstances of the fall as soon as possible, what falls prevention interventions were (or were not) in place at the time of the fall, any contributing factors and the post fall follow up/action plan.

2 A post-fall checklist is being prepared for testing on Ward 4 (assessment, treatment and

rehabilitation) in June/July. The checklist is based on a form in use at Waitemata DHB which has been modified for use at CM Health for the purpose of this test. The checklist includes information about the fall, the immediate response, check for any injury and plan and actions taken immediately around the fall. This PDSA is to test whether completing the checklist assists with decision making, prompts immediate action after the fall and provides clearer documentation about the fall for the purpose of incident reporting and case review.

Certification Update Work to resolve corrective actions continue, with no further reporting to the MoH required until August 2017. The next Certification visit is scheduled for November 2017. Complaint Review Update One of the corrective actions from the last Certification audit was to improve our complaint process for complaints and Serious and Sentinel Events (SSE). The complaint review is complete and options are being developed. The need to strengthen reporting from our Risk Management System and make available a Corrective Action Database was also highlighted. Alternative options for a Corrective Action Database are being actively explored. Two workshops have been held with the Clinical Quality and Risk Managers to identify format and required resource. Leadership Nursing Regular national Nurse meetings with Directors of Nursing, Health Workforce NZ (HWNZ), MoH, Nurse Executives, and Health Roundtable sessions continue to be attended by Senior CM Health nurse representatives. These provide networking and strategic planning opportunities. The New Zealand Nursing Workforce Programme Governance Group met in May. The Governance Group includes DHB Chief Executive Officers (CEOs), and Directors of Nursing, CEOs from Primary Health Organisations and New Zealand Aged Care Association along with Pacific and Maaori nursing and a consumer representative. Outcomes identified were the review of the current vocational training model and exploration of barriers to the effective utilisation of primary health care nurses and Nurse Practitioner employment. Work continues with the Health Workforce New Zealand (HWNZ) Nursing Taskforce.

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The Chief Nurse Primary and Integrated Care holds the New Zealand Nursing Cancer Portfolio. Work includes a national stocktake of closed system transfer devices as determined by the national standards for chemotherapy administration released in 2016. Midwifery The Midwifery Strategic Advisory Group (MSAG) is a partnership approach between HWNZ and representatives from the midwifery profession, midwifery education sector and the wider health workforce. The purpose of the MSAG is to provide strategic advice and guidance to the MoH and the sector to ensure a sustainable and supported midwifery workforce. The MSAG will lead the development of a midwifery work plan over a 2-3 year timeframe. The Director of Midwifery is one of the national DHB representatives on the working group. The DHB Midwifery Leaders will be meeting with the MoH and the HWNZ Analytics Manager on 3 July 2017 to assist in contextualising the data and planning to meet the projections required. Allied Health In May, the Associate Director Allied Health Dietetics presented to the NZ Society for the Study of Diabetes (NZSSD) Dietician Study day in Dunedin. The presentation focus was the ‘National Knowledge, Skills and Career Framework for Diabetes Dieticians’, and its national implementation. Work will commence on a national accreditation portfolio process for Specialist Diabetes Dieticians, along with a post graduate course at the Waikato Institute of Technology (WINTEC). The Associate Director Allied Health Dietetics also attended the national teleconference on the implementation and development of a national standard on malnutrition. The group is creating a new standard that will be utilised by all dieticians across NZ. This will incorporate a national definition of malnutrition, and treatment and intervention guidelines. The Australasian Society Study for Brain Impairment (ASSBI) was attended by the Associate Director Allied Health Speech Language Therapy. Topics included narratives in health care, assessment and treatment of pragmatic communication disorders, and group work in aphasia (including manual provision) which will be implemented in Franklin Locality mid-year. The national speech language therapy health leaders recently held their bi-annual teleconference. The focus of the teleconference was on auditing the national strategy around diet modification.

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Appendix 1 - Undergrad Education Landscape Introduction CM Health is committed to being a clinical 'teaching' health care facility for the range of professions that deliver health care services. We recognise that these students are our future workforce. High quality clinical opportunities as part of undergraduate health care education are critical to providing a workforce that delivers high quality care. Having undergraduates completes placements within our services benefits both CM Health and the students - professionally and practically. Nevertheless, we need to balance this approach, mindful of the available capacity of our current workforce, and the busy environment of the hospital. These factors can adversely affect ensuring good preceptor/supervision and teaching opportunities for the students, and creating a positive impression of CM Health as a desirable place to learn and to seek future employment. The Undergraduate Education Team This team (3.5 FTE) is a part of Building Capability - Ko Awatea, and manage the arrangements for clinical placements of Nursing, Midwifery and Allied Health students. The Undergraduate team work closely with tertiary providers to plan, co-ordinate and support clinical placements of students within the Counties Manukau region, including at CM Health, private providers, and non-governmental organisations (NGO’s) to prepare students to gain professional registration competencies requirements and future employment. The Undergraduate Education Team manages the Clinical Access Agreements and placement negotiation directly with the tertiary providers. They hold data on placement allocations of students, roster hours and manage invoicing to tertiary providers. CM Health has Clinical Access Agreements with 13 NZ tertiary providers, who provide undergraduate level Health Professions programmes (refer Summary). These are five-year agreements, to ensure a consistent approach to clinical placements. The 2017 renewal of these agreements included additional safety checks required by the Vulnerable Children Act, updated occupational health screening and workplace health and safety requirements. An orientation module has been developed (online via KA LEARN) for all students to complete. This includes information to prepare for their clinical placement and orientate to CM Health. The module includes patient safety training, privacy and occupational health requirements. The role of the co-ordinators includes providing; • Liaison with tertiary providers • Planning and allocation of placements • Supervisor/Preceptor training and mentoring • Pre-placement preparation, and initial orientation of students • Coaching and mentoring of undergraduate students • Inter-professional learning opportunities Clinical preceptors, educators, professional leads and academic liaison also support students while on placements. Students contribute to direct patient care and experience while on placement at CM Health. Graduates who have completed placements (particularly in their final year) are well placed for employment at CM Health upon graduation. There is a particular focus to employing those graduates who participated in the local secondary school Health Academy and scholarships.

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Inter-professional Focus Inter-professional student workshops are hosted several times each year by the Ko Awatea Building Capability team. These create opportunities for students from different tertiary providers and professions to learn “with, from and about” each other whilst at CM Health. Students and tertiary partners strongly endorse these, and they are creating a positive shift in the students’ perceptions of inter-professional collaboration and the importance of teamwork. In addition, the Ko Awatea partnership provides ‘on-site’ clinical teaching of students using Ko Awatea facilities. Students participate in patient experience and co-design learning activities, such as the empathy zone and listening café that are part of the annual CM Health patient experience week. Nursing Clinical Placements As part of all undergraduate nursing programmes, the New Zealand Nursing Council requires a minimum of 1,100 clinical practice hours. These are designed to enable students to undertake nursing care with people in any context (Nursing Council of New Zealand, 2010). Nursing supports the most student placements, predominately to the MIT programmes. In 2016, 902 placements were provided to students across the three years of undergraduate study - ranging from single day visit in year 1 to 12-week transition to practice in year 3.

Programme 2016 Placements

MIT Bachelor of Nursing 660

MIT Bachelor of Nursing - Pacific 74

Diploma of Enrolled Nursing 72

University of Auckland’s Bachelor of Nursing 91

Other NZ tertiary providers/international students 5 Dedicated Education Units Over 50% of nursing placements are within a Dedicated Education Unit (DEU). These are clinical units, such as a ward or community service that are supported to provide an optimal teaching and learning environment for student placements through the collaboration of clinical and academic staff within the health care environment. A DEU has a strong focus on student teaching and learning, assisted and supported by a Clinical Liaison Nurse (CLN) appointed from within the clinical area and an Academic Liaison Nurse (ALN) appointed by MIT. The DEU model is a joint initiative between MIT and CM Health, first established in 2009, from a model developed by Flinders University in South Australia. A formal evaluation occurred with funding from the Ako Aotearoa national project funding. There are now Dedicated Education Units in: • Medicine (Ward 2, 32N, 33N/E) • ARHOP (Ward 4/5 and 23/24) • Surgical (Ward 9) • Orthopaedics (Ward 10/11) • Manukau Surgery Centre (1 and 2) • Perioperative Care – Theatres MMH and MSC • Mental Health: (acute, older people, liaison)

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There is also a DEU in conjunction with the Howick Baptist Hospital (aged residential care). In 2016, building on the success of DEU model for nursing education, the concept was expanded for other health professionals on placements in Peri-operative (Theatres) and the concepts are used in Kidz First to foster inter-professional student learning and teamwork. Allied Health Placements The Allied Health professions also require minimum clinical practice hours according to the various professional governing bodies. In 2016, twelve Allied Health, Scientific and Technical professions offered approximately 440 clinical placements, with the highest number of allied health placements from Auckland University of Technology (AUT) including Physiotherapy (120 students), Occupational therapy (70 students) and Para-medicine (140 students). Placement type and length can vary and include a range of opportunities from observed to supervised clinical practice. There are a variety of mechanisms to support Allied Health clinical staff in provision of placements within teams. However, it can still be challenging to schedule placements, particularly in smaller Allied Health professions, if there is a shortage of suitable experienced clinical staff to provide the teaching and supervision students require. Conclusion CM Health provides efficient, effective coordination and provision of undergraduate clinical placements in conjunction with our tertiary partners. The scheduling of placements is negotiated with clinical service teams, and capacity will always depend on specific placement timing, levels and length. For Nursing, the focus on our local tertiary partners’ means that MIT and UoA contract obligations have priority for placement spaces within DEU’s – accommodating other institutions is dependent on capacity. The Primary Health Organisations work directly with MIT for primary care placements. Each year, total tertiary provider’s requests increase, and planning for this is occurring. We are currently experiencing a spike in requests for Nursing and some Allied Health placements in 2017, after a period of stability. There are a number of factors contributing to this growth – including new programmes, more student enrolments, and greater student success within the programmes. Placement requests now also come from increasing numbers of out-of-area entities. The Undergraduate Education team also support the co-ordination of additional placements and visits, including overseas health professional visits, the Nursing return to work (‘Competency Assessment Programme’ (CAP) – run by MIT), and change of scope placements. In 2016, eight CAP nurses completed six-week placements across acute care, surgical and mental health. There are strong relationships with tertiary providers at a range of levels – for example, the Collaborative Nursing Development Unit (CNPU) and regular sessions hosted between professional leads and the tertiary provider heads of school/teaching staff. There are a number of joint appointment roles shared by CM Health and tertiary providers – notably with UoA and AUT. These networks assist with identifying and addressing the range of issues and requirements for providing high quality, relevant undergraduate education to our future workforce.

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Summary of Providers and Programmes

Tertiary Providers with Clinical Access Agreements

Nursing & Midwifery Programmes

Allied Health Programmes

Auckland University of Technology (AUT)

Nursing Midwifery

Occupational Therapy Physiotherapy Medical Laboratory Paramedics Podiatry

ARA Institute of Canterbury Medical Radiation Technology

Massey University

Nursing

Clinical Psychology Dietetics Medical Laboratory Speech Language Therapy Social Work

MIT

Nursing - including • BN – Pacific • Enrolled Nursing

Clinical Renal Physiologist Social Work

UNITEC

Nursing

Social Work Medical Radiation Technology

University of Auckland (UoA)

Nursing

Audiology Dietetics Pharmacy Clinical and Health Psychology Social Work Speech Language Therapy Optometry

University College of Learning (UCOL)

Nursing

Medical Radiation Technology

University of Canterbury

Health Psychology Social Work Speech Language Therapy

Te Wananga o Aotearoa

Education Social Work

Te Whare Wananga o Awanuiarangi

Nursing • BN – Maaori

Otago Polytechnic

Nursing Midwifery

Occupational Therapy * includes students enrolled at Wintec

Otago University Medical Laboratory Pharmacy

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Human Resources (HR) HR metrics are provided to outline performance for Annual Leave Balances, Sick Leave and Turnover rates. Below are the 12 month trend graphs to April 2017.

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

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

Sick Leave Sick Leave LY UCL Average LCL

6%7%8%9%

10%11%12%

Annualised CMDHB Voluntary Turnover (Hospital Directorate Only)

Turnover Turnover LY UCL Average LCL

7%8%9%

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

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

> 2 Years > 2 Years LY UCL Average LCL

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0%

4%

8%

12%

16%

20%

Annual Leave Paid as Percentage of Total Paid Hours May 2016 to April 2017

AL Paid % AL Paid % LY UCL Average LCL

0 10 20 30 40 50 60 70 80

May'16

Jun'16

Jul'16

Aug'16

Sep'16

Oct'16

Nov'16

Dec'16

Jan'17

Feb'17

Mar'17

Apr'17

Voluntary Employee Turnover by Reason for Leaving May 2016 to April 2017

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

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Response to Action Item Actions previously assigned by the Hospital Advisory Committee are reported back on in this section. HAC Meeting 8.3.2017 – Summary of Annual Leave Cash Ups for Hospital Services Directorate “Provide a quarterly report showing, for those staff that have had annual leave paid out, their current leave balance, leave accrual and leave taken. This report is not to specifically identify individuals due to privacy issues”.

Summary of Annual Leave Cashups within the Hospital Services Directoratefor the period 1st January to 31st May 2017

Department Name AL Cash up CategoryTtl AL Cash

Up (hrs)Current AL

Balance (hrs)Ttl AL Taken in

12mths (hrs)

Acute Allied Annual Leave Reduction Project 51.38 187.54 60.00 Adult Emergency Care Annual Leave Reduction Project 47.49 524.35 166.00 Anaesthesiology Annual Leave Reduction Project 80.00 365.19 25.00

Other 68.00 227.16 185.00 Birthing & Assessment Unit Annual Leave Reduction Project 430.22 433.22 56.00 Intensive Care Unit (ICU) Annual Leave Reduction Project 60.53 420.38 232.00 NICU Annual Leave Reduction Project 180.10 322.51 144.00 Pharmacy Annual Leave Reduction Project 51.55 270.62 231.50

Other 109.69 179.47 78.00 Renal Services Other 167.01 503.38 232.00 Ward 9 Annual Leave Reduction Project 240.78 628.95 220.00 Geriatric A&R - Medical Staff Annual Leave Reduction Project 245.87 421.47 96.00 Respiratory Medicine Annual Leave Reduction Project 16.21 218.05 85.20 Manchester Plastic Surgery Suite Annual Leave Reduction Project 192.73 512.73 152.00 Cleaning MMH Family 187.11 326.31 144.00 Grand Total 2,128.67 5,541.33 2,106.70

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




2.1 Public Excluded Minutes of 31 May 2017

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

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

2.2. Action Items Register

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 Action Items Register For the reasons given in the previous meeting.

3.1 Patient Experience and Safety Report

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

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

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