QUALITY ACCOUNT · We have 182 beds at Rotorua Hospital, including the Special Care Baby Unit,...
54
1 QUALITY ACCOUNT 1 July 2012 - 30 June 2013
Transcript of QUALITY ACCOUNT · We have 182 beds at Rotorua Hospital, including the Special Care Baby Unit,...
1
QUALITY ACCOUNT
1 July 2012 - 30 June 2013
1
Foreword
Lakes DHB is delighted to present its first ever quality account, for the period 1 July 2012-30 June 2013.
Quality is important to our patients, staff and our organisation, and we were pleased to host the Midland DHBs’ regional launch of the national Patient Safety Campaign on Friday 17 May, at Rotorua Hospital.
Lakes DHB is focusing on falls prevention for the first six months of patient safety programme. The other areas of focus for the campaign will be surgery, healthcare associated infections and medication safety.
This document contains many examples of quality initiatives resulting in services to improve patient safety, clinical effectiveness and patient outcomes.
The studies in this document demonstrate a passion and commitment by our staff to make a difference for our patients.
This very much aligns with my own enthusiasm and commitment to providing safe effective healthcare to our community.
Thanks to all those involved with the efforts to bring this first Lakes DHB Quality Account to completion.
Ron DunhamChief Executive
2
Introduction to Quality Account
This Quality Account is Lakes DHB’s first report to the public and other stakeholders about the quality of services we provide. It represents an important part of our work and that we believe patients are at the centre of all that we do. The account outlines our commitment to improving services and to be transparent and accountable to patients, the public, colleagues, board and others.
This Quality Account presents some of our quality improvement initiatives in terms of patient safety, patient experience, clinical effectiveness, integration and workforce and demonstrates that our clinical teams, support staff and management are all committed to providing continuous, evidence based, quality care to the people we treat. We are pleased that included are some great initiatives with contributions to
the document from clinical and support staff as well as primary care.
Our focus is on maintaining and improving quality whist reducing costs by increasing productivity and redesigning services wherever possible. Lakes DHB’s Clinical Governance Executive Group, which consists of the Chief Executive, Chief Medical Advisor, Director of Nursing & Midwifery, General Manager Clinical Services, Quality & Risk Manager, and Innovation, Improvement & Quality Clinical Directors, supports the Innovation and Improvement framework.
A number of staff have contributed to the content of this report and the initiatives reflect what is important to them and their patients. We wish to acknowledge their work and commitment to improving the quality care for patients.
This inaugural Quality Account showcases some of the tremendous work done at Lakes DHB. They are a testament to the commitment, passion and hard work that our staff have demonstrated to improve the care of our population.
I hope that these stories will reflect our vision to constantly improve the care we deliver to patients and to inspire others within the organisation to continue to do more. Improving the quality of care we provide will help address some of the huge challenges for healthcare and while this is a great demonstration of some of the improvements on our journey, we still have a long way to go.
Martin ThomasLakes DHB Chief Medical Officer
3
These quality accounts describe innovative and committed work done by teams of people working together to improve health outcomes for the community we serve. Continuously improving what we do has caught on as a vision for these teams.Acknowledging what has been achieved can help inspire others to think about what we can do together to improve our services. This is a responsibility for all of us.Our key areas of focus are; improving the quality and safety of health care, looking after and employing the right workforce and supporting staff to deliver the right care to the right people at the right place and time.In 2013 our aim is to engage our patients more in improving and designing services.
Dr Denise Aitken Clinical Director Quality & Innovation
Compiling this first Quality Account has been a real journey of discovery of how many excellent quality improvement projects are happening within different departments across the organisation. All of them display a desire to improve patient care innovatively and beyond the compliance level of basic standards of care.
The quality projects have a true patient focus and aim to involve patients in their own care, setting goals with them and thereby improving their health care experience and outcomes.
I see this report marking the beginning of our quality improvement journey to become an exemplar hospital, leading the way, not just achieving bottom line results.
Dr Ulrike Buehner Clinical Director Quality & Innovation
The information in this inaugural quality publication clearly demonstrates that staff at our DHB and in primary care have patients at the centre of all that they do.Lakes DHB clinical and support staff and management have a strong commitment to maintain and improve quality at the same time as reducing costs by increasing productivity and redesigning services wherever possible.The development of this publication is an important part of showcasing just where we have reached in the continuous process of quality improvement and care to our patients of Rotorua and Taupo. A sincere thank you to all those people who gave generously of themselves to deliver this important first Quality Account for Lakes DHB.
Dale OliffGeneral Manager Clinical Services
4
5
ContentsForeword by Chief Executive Ron Dunham . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Introduction to Quality Account Martin Thomas Chief Medical Officer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Denise Aitken and Ulrike Buehner, Clinical Directors Quality & Innovation . . . . . . . . . . . . . . . . . . . . 3 Dale Oliff, General Manager Clinical Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Our services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7The right six . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Our priorities for improvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Acknowledgements of our staff in 2012/13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Patient Safety Patient falls prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Falls Champion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Red Socks Campaign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Safe Sleeping (Pepi Pod Programme) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 VTE Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Patient Safety and Clinical Effectiveness Lakes DHB Research and Ethics Committee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Patient Safety and Integration Vulnerable Unborns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Lakes Heart Health Group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Patient Experience Mirimiri for Patient Comfort . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Whanau Room. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 An Improved Service Delivery for Skin Cancers of the Head and Neck . . . . . . . . . . . . . . . . . . . . . . 27 Buckeye Meal System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Patient Experience and Clinical Effectiveness Improving Referral Pathway to Mobile Ear Clinic Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Endoscopy at Lakes DHB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Simulation Unit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31Clinical Effectiveness Closed Chemotherapy Administration System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Introducing Txt Reminders for Specialist Outpatient Appointments . . . . . . . . . . . . . . . . . . . . . . . . . 34 Clinical Handover . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36Clinical Effectiveness and Integration Trauma Care Quality Improvement Programme . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38Clinical Effectiveness and Workforce Paediatric E-Learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40Clinical Effectiveness Improvement in Changing Sterility Method of Nasendoscopes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41Integration Best Practice Support for Primary Care Programme. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Newborn Enrolment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44Workforce Maori Health - Kia Ora Hauora and Matakokiri Initiatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Taleo Online Recruitment System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46Health TargetsSecondary Care Smoking Target . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47Primary Care Help for Smokers to Quit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48Shorter Stays in ED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49Improved Access to Elective Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50Priorities for 2013/14 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
6
7
Our services
Lakes District Health Board is responsible for the provision of publicly funded health services for the region. These services cover primary care, some NGO services, Well Child services, mental health services, health of older people services as well as specialist secondary services.
Primary care is the cornerstone of our health system with most people having some interaction with these services. The Lakes DHB region is well supported with excellent primary services which belong to one of the two primary health organisations (PHO), which are Health Rotorua PHO and the Midlands Health Network, including Taupo and Turangi primary care teams. There are 21 GP practices (five in Taupo/Turangi/Mangakino and 16 Rotorua). Many patients also have treatments provided by tertiary services at Waikato or Auckland Hospitals.
The Lakes DHB Hospital and Specialist Secondary Services (H&SSS), the provider arm of Lakes DHB, is responsible for the delivery of core specialist secondary hospital and community based health services to the people of the Lakes DHB region. These services are mainly delivered from hospitals based in Rotorua and Taupo with a small number delivered from off site facilities. Clinical services include acute, emergency and inpatient services; elective inpatient, outpatient and ambulatory services; mental health services; a range of secondary level diagnostic services; community nursing and some allied services. We have 182 beds at Rotorua Hospital, including the Special Care Baby Unit, maternity and mental health units. Approximately 108 beds are available for medical and surgical patients (including critical care and coronary care) with a further 43 for maternity and children and 16 for older people. Some 12 beds are designated for mental health patients. The busy emergency department has 32 cubicles and outpatients have 28 consultation rooms. Patients also attend for physiotherapy and other treatments.
Taupo Hospital is a sub acute, level 3 rural hospital, providing some medical and rehabilitation services with ambulatory clinics and day stay surgery. We have 25 beds at Taupo Hospital including maternity and day stay. The emergency department has 6 cubicles currently and outpatient clinics are also held on site.
25,636 Discharges from hospital
3.34 Average length of stay (days) for medical patients
2.22 Average length of stay (days) for surgical patients
8,023 Total surgical operations
3,638 Number of elective procedures
45% Electives proportion of all surgical procedures as opposed to acutes
42,365 Specialist outpatient attendances
41,307 Emergency Department attendances
1476 Babies delivered in Rotorua & Taupo Hospitals
28,491 Children served by school dental service
4,796 Inpatient mental health days of care
4,296 People seen by specialist & support community mental health services
2012-13
8
The right six is our overarching model of care, ensuring that the patient always comes first. The right six is based on the – right patient (patient flows), receiving the right care (delivery systems), in the right place (settings of care), at the right time (service delivery), by the right team (workforce), at the right price (outcome).
The new inpatient and ambulatory building on the Rotorua Hospital site, Whakaue Rauoranga, was commissioned in 2011. The theatre suite expansion to five theatres plus endoscopy suite was completed early in 2013. Planning is well underway for the refurbishment of Taupo Hospital to allow for reconfiguration of the emergency department and outpatient services, co-location of maternity services as well as bringing community mental health on to the site, which is due to commence in the first half of 2014.
Our services are configured into seven business units, each led with a clinical director, clinical nurse director and service manager. Support is provided to the services by human resources, quality and risk and management accountant teams.
Clinical leadership is the cornerstone of achieving our goals and targets with a focus on performance measurement on key results. We will be judged on our results by our stakeholders, be they patients, our staff, the Board, National Health Board, the public and the community. l We will continue to put people at the heart of our system l To develop effective and enduring partnerships between clinicians, clinical teams and between primary, secondary and tertiary services l To foster clinical and managerial networks inter and intra regionally, nationally and internationally
9
Our priorities for improvement
We have identified the following fundamental elements for the 2012-13 Quality Account and we have elected to report against this framework. Many of the initiatives are in more than one category. The majority of the initiatives included in this report have been developed as a result of staff wanting to make improvements to the way they deliver care. Others have been the result of a patient complaint, while some are from regional, national or international work programmes.
Fundamental elements of quality care
Patient safety l Patients are safe and free from harm – Although there are some initiatives that have been identified as specifically to support patient safety this is a core concept in all the work that we do.We have a number of patient safety measures in place and all have work programmes to support them, some of which are described in this document. l Harm from falls - our target is to have zero harm from falls in the organisation. l VTE (blood clots) risk assessment l Infection control – we align with the national work programmes and monitor l Surgical site infections l Hospital acquired infections l Hand washing – we have implemented the national programme and have audited the hand washing moments. l Incident reporting – the Quality & Risk team manages the incident reporting database and feeds into the individual service clinical governance and quality meetings.
Patient experience l Patients, their families and whanau have a warm experience that meets or exceeds their expectations. From warm welcomes to fond farewells. l We review the patient satisfaction surveys, investigate and act on complaints and listen to patients at an individual clinician level.
Clinical quality and effectiveness l The care and treatment we deliver is the best available and cost effective, so that patients are safe, receive the best care and we don’t waste the precious health dollar. l Clinical audit identifies areas for improvement.
Workforce l We have the right people, with the right skills, giving the right care in the right place at the right time.
Integration, better, sooner, more convenient l We are looking at the whole continuum of care so work closely with our community, primary and tertiary colleagues. l Clinical pathways are the vehicle that identify patient flows through the continuum to ensure that care is better coordinated and we have implemented three this year, with work commenced on others.
10
My
Dis
tric
t H
ealt
h B
oard
00
Dis
tric
t H
ealt
h B
oard
00%
–
DH
B c
urr
ent
per
form
ance
GO
AL
Rank
ing
How
to re
ad th
e gr
aphs
Prog
ress
Qua
rter
four
pe
rfor
man
ce
2012
/13
QU
ARTE
R F
OU
R (A
PR
IL-J
UN
E) R
ESU
LTS
Th
is in
form
ati
on s
hou
ld b
e re
ad
in c
onju
nct
ion
wit
h th
e d
eta
ils
on th
e w
ebsi
te w
ww
.hea
lth
.gov
t.n
z/h
ealt
hta
rget
s
Elec
tive
Sur
gery
Impr
oved
acce
ss to
Emer
genc
y D
epar
tmen
ts
Shor
ter
stay
s in
Imm
unis
atio
n
Incr
ease
d
Sm
oker
s to
Qui
t
Bet
ter
help
for
Chan
ge fr
om
prev
ious
qu
arte
rH
ospi
tals
Prim
ary
care
Chan
ge fr
om
prev
ious
qu
arte
r
Chan
ge fr
om
prev
ious
qu
arte
r
Chan
ge fr
om
prev
ious
qu
arte
r
Sho
rter
sta
ys in
Em
erge
ncy
Dep
artm
ents
Th
e ta
rget
is 9
5 pe
rcen
t of
patie
nts
will
be
adm
itted
, di
scha
rged
, or t
rans
ferr
ed fr
om
an E
mer
genc
y D
epar
tmen
t (ED
) w
ithin
six
hou
rs. T
he ta
rget
is
a m
easu
re o
f the
effi
cien
cy o
f flo
w o
f acu
te (u
rgen
t) p
atie
nts
thro
ugh
publ
ic h
ospi
tals
, and
ho
me
agai
n.
Impr
oved
acc
ess
to e
lect
ive
surg
ery
Th
e ta
rget
is a
n in
crea
se in
th
e vo
lum
e of
ele
ctiv
e su
rger
y by
at l
east
400
0 di
scha
rges
pe
r yea
r. D
HB
s pl
anne
d to
de
liver
148
,259
dis
char
ges
for
the
2012
/13
year
, and
hav
e de
liver
ed 1
0,22
3 m
ore.
Hea
rt a
ndD
iabe
tes
Chec
ks
Qua
rter
fo
ur
perf
orm
ance
(%)
Qua
rter
four
pe
rfor
man
ce (%
)
Qua
rter
fo
ur
perf
orm
ance
(%)
Qua
rter
fo
ur
perf
orm
ance
(%)
Chan
ge fr
om
prev
ious
qu
arte
r
Prog
ress
ag
ains
t pla
n (d
isch
arge
s)
Qua
rter
fo
ur
perf
orm
ance
(%)
Chan
ge fr
om
prev
ious
qu
arte
r
Qua
rter
fo
ur
perf
orm
ance
(%)
Sho
rter
wai
ts fo
r can
cer
trea
tmen
tTh
e ta
rget
is a
ll pa
tient
s, re
ady-
for-
trea
tmen
t, w
ait l
ess
than
fo
ur w
eeks
for r
adio
ther
apy
or
chem
othe
rapy
. Six
regi
onal
can
cer
cent
re D
HB
s pr
ovid
e ra
diat
ion
onco
logy
ser
vice
s. T
hese
cen
tres
ar
e in
Auc
klan
d, H
amilt
on,
Palm
erst
on N
orth
, Wel
lingt
on,
Chri
stch
urch
and
Dun
edin
. M
edic
al o
ncol
ogy
serv
ices
are
pr
ovid
ed b
y th
e m
ajor
ity o
f DH
Bs.
Canc
er T
reat
men
t
Shor
ter
wai
ts fo
r
Incr
ease
d Im
mun
isat
ion
The
natio
nal i
mm
unis
atio
n ta
rget
is 8
5 pe
rcen
t of e
ight
-m
onth
-old
s ha
ve th
eir p
rim
ary
cour
se o
f im
mun
isat
ion
at s
ix
wee
ks, t
hree
mon
ths
and
five
mon
ths
on ti
me
by Ju
ly 2
013,
90
per
cent
by
July
201
4 an
d 95
per
cent
by
Dec
embe
r 201
4.
This
qua
rter
ly p
rogr
ess
resu
lt
incl
udes
chi
ldre
n w
ho tu
rned
ei
ght-
mon
ths
betw
een
Apr
il an
d Ju
ne 2
013
and
who
wer
e fu
lly
imm
unis
ed a
t tha
t sta
ge.
Bet
ter h
elp
for s
mok
ers
to q
uit
The
targ
et is
95
perc
ent o
f pa
tient
s w
ho s
mok
e an
d ar
e se
en b
y a
heal
th p
ract
ition
er
in p
ublic
hos
pita
ls, a
nd
90 p
erce
nt o
f pat
ient
s w
ho
smok
e an
d ar
e se
en b
y a
heal
th p
ract
ition
er in
pri
mar
y ca
re, a
re o
ffer
ed b
rief
adv
ice
and
supp
ort t
o qu
it sm
okin
g.
Mor
e he
art a
nd d
iabe
tes
chec
ksTh
is ta
rget
is 9
0 pe
rcen
t of t
he
elig
ible
pop
ulat
ion
will
hav
e ha
d th
eir c
ardi
ovas
cula
r ris
k as
sess
ed in
the
last
five
yea
rs
to b
e ac
hiev
ed in
sta
ges
by Ju
ly
2014
. The
cur
rent
sta
ge is
to
achi
eve
75 p
erce
nt b
y Ju
ly 2
013.
95%
100%
100%
85%
90%
75%
95%
From
nex
t qu
arte
r, so
me
leve
l tw
o em
erge
ncy
dep
artm
ent
faci
litie
s w
ill
be in
clu
ded
in t
he t
arge
t.
Hea
lth
targ
et re
sult
s ar
e so
urce
d fr
om in
divi
dual
DH
B re
port
s, n
atio
nal c
olle
ctio
ns s
yste
ms
and
info
rmat
ion
prov
ided
by
prim
ary
care
org
anis
atio
ns.
1W
est C
oast
100
–2
Wai
rara
pa97
–3
Wha
ngan
ui97
–4
Nel
son
Mar
lbor
ough
97–
5H
utt V
alle
y97
6S
outh
Can
terb
ury
96–
7W
aite
mat
a96
8Co
untie
s M
anuk
au96
–9
Tara
naki
96–
10Ca
nter
bury
95
11A
uckl
and
95–
12Ta
iraw
hiti
95–
13H
awke
’s B
ay93
–14
Nor
thla
nd92
15La
kes
92
16S
outh
ern
91
17B
ay o
f Ple
nty
90–
18W
aika
to88
–19
Capi
tal &
Coa
st87
20M
idCe
ntra
l86
All D
HB
s93
–
1N
orth
land
124
2H
awke
’s B
ay11
7
3La
kes
115
4W
aika
to11
5
5Ta
rana
ki11
2
6Co
untie
s M
anuk
au11
1
7B
ay o
f Ple
nty
108
8M
idCe
ntra
l10
6
9Ca
nter
bury
106
10S
outh
Can
terb
ury
106
11W
est C
oast
106
12H
utt V
alle
y10
5
13Ta
iraw
hiti
105
14S
outh
ern
102
15Ca
pita
l & C
oast
101
16W
aite
mat
a10
1
17A
uckl
and
101
18N
elso
n M
arlb
orou
gh10
0
19W
aira
rapa
100
20W
hang
anui
100
All D
HB
s10
7
*
1N
orth
land
100
–1
Wai
tem
ata
100
–1
Auc
klan
d10
0–
1Co
untie
s M
anuk
au10
0–
1W
aika
to10
0–
1La
kes
100
–1
Bay
of P
lent
y10
0–
1Ta
iraw
hiti
100
–1
Haw
ke’s
Bay
100
–1
Tara
naki
100
–1
Mid
Cent
ral
100
–1
Wha
ngan
ui10
0–
1Ca
pita
l & C
oast
100
–1
Hut
t Val
ley
100
–1
Wai
rara
pa10
0–
1N
elso
n M
arlb
orou
gh10
0–
1W
est C
oast
100
–1
Cant
erbu
ry10
0–
1S
outh
Can
terb
ury
100
–1
Sou
ther
n10
0–
All D
HB
s100
–
1W
hang
anui
96
2H
awke
’s B
ay95
3S
outh
ern
95
4M
idCe
ntra
l94
–5
Wes
t Coa
st93
6W
aira
rapa
93
7Ca
nter
bury
92–
8Ca
pita
l & C
oast
92–
9W
aite
mat
a92
10H
utt V
alle
y91
11A
uckl
and
90–
12Co
untie
s M
anuk
au90
13Ta
rana
ki89
–14
Taira
whi
ti89
15B
ay o
f Ple
nty
89–
16S
outh
Can
terb
ury
88
17N
elso
n M
arlb
orou
gh87
–18
Lake
s86
–19
Wai
kato
83
20N
orth
land
83–
All D
HB
s90
–97
1W
aira
rapa
96
–98
2H
awke
’s B
ay80
–99
3S
outh
Can
terb
ury
76
–99
4B
ay o
f Ple
nty
74
–98
5N
orth
land
72
–90
6M
idCe
ntra
l67
–95
7Ca
pita
l & C
oast
66
97
8Ta
rana
ki65
–96
9W
hang
anui
62
95
10N
elso
n M
arlb
orou
gh61
96
11W
aika
to61
98
12La
kes
61
96
13S
outh
ern
56
–95
14Co
untie
s M
anuk
au56
95
15W
est C
oast
55
95
16Ta
iraw
hiti
54
–97
17H
utt V
alle
y51
–96
18A
uckl
and
48
–97
19W
aite
mat
a43
93
20Ca
nter
bury
35
96
All D
HB
s57
1A
uckl
and
81
2W
aira
rapa
81
3Ca
pita
l & C
oast
76
4Co
untie
s M
anuk
au76
5N
orth
land
74
6Ta
rana
ki73
7W
aika
to73
8H
awke
’s B
ay72
9W
hang
anui
72
10B
ay o
f Ple
nty
72
11W
aite
mat
a71
12Ta
iraw
hiti
68
13M
idCe
ntra
l68
14La
kes
66
15S
outh
Can
terb
ury
64
16S
outh
ern
63
17W
est C
oast
58–
18N
elso
n M
arlb
orou
gh57
19H
utt V
alle
y49
20Ca
nter
bury
32
All D
HB
s67
11
Health targetsThe Health Targets are set by the Minister of Health and all DHBs are required to meet these, reporting is quarterly. The following are a sample: l Shorter stays in ED l Improved access to elective surgery l Better help for smokers to quit
Monitoring and measuringAs well as the Health Targets and the Health Quality and Safety Commission’s quality and safety markers, indicators and atlas of healthcare variation, we use a number of other tools to monitor our performance. These include: l Balanced Scorecard which shows performance against a number of indicators l Clinical audit – each of the clinical teams have a clinical audit process in which they review cases and identify areas for improvement l Incident and complaints management – led by the quality and risk team with investigations at a team and service level as well as whole of system level l Case note review using the Global Trigger Tool – is a method of identifying the rate of adverse events which may cause harm and highlights trends in areas for improvement l Monitoring the use of the risk assessment tools for admitted patients l Health Roundtable Reports l Hospital quality and productivity reports
This report only describes a sample of the quality improvement work that has taken place across the Lakes DHB region.
“Patient outcomes and patient safety are absolutely at the core of the work of health care
providers. Publishing a quality account helps us show our staff and patients that
we are committed to improving the quality of what we do.”
Gary Lees Director Nursing & Midwifery
12
Acknowledgements of our staff in 2012/13
Lakes DHB’s leadership supports staff getting education to improve the delivery of care to patients and on the 19th November 2012 the inaugural ceremony for clinical scholarships, quality and staff awards was held in the atrium of the new Rotorua Hospital.Three Stolwyk clinical education scholarships were awarded to Lakes DHB staff for post-graduate study for 2012.The scholarships are made possible by a bequest from the estate of Rotorua man, Mr G Stolwyk. When Lakes DHB received a substantial bequest from Mr Stolwyk in 2008 the trustees set aside a scholarship fund with the interest earned used for scholarships to support post graduate study for clinical staff. l Wendy Ayre, Taupo Staff Nurse is taking emergency management papers. l Sukhbir Duggal, Staff Nurse from OPRS is studying towards a post graduate qualification in Health Sciences, Clinical Rehabilitation. l Waverley Newson, Lakes DHB Infection Control Nurse Specialist is studying for a post graduate Certificate in Infection Control. Waverley received one of the inaugural Stolwyk scholarships in 2010 to help fund study towards her Masters of Advanced Practice with a post graduate certificate paper on the “Sciences of Infection and Disease,” at Griffith University in Australia.
A leadership focus on recognising excellence in improving and delivering care was behind the Lakes Quality Awards, which provide public recognition of the importance of delivering quality care. The recipients in 2012 were:Anaesthetist Dr Ulrike Buehner received the ROSS BOHM CLINICAL QUALITY INITIATIVE AWARD, in recognition of her VTE (Venous Thromboembolism) Prevention Programme work and her work with the Midland Regional Trauma system. This new award is to recognise a DHB senior medical staff member who has demonstrated a significant clinical quality improvement or initiative with a clear patient or health system-focused outcome.
Outpatients Receptionist for the Antenatal Clinic, Kiri McRae received the ADMINISTRATION AWARD, after being nominated for it by 13 different members of staff. They describe Kiri as providing a cheerful reception to all those coming to the Maternity Unit. Her extensive knowledge of the DHB systems allows the very busy antenatal schedules to operate seamlessly. She is described as a model of administrative staff and how her personality and skill set make her a kiwihost extraordinaire, and someone who makes a huge difference for patients.
Charge Mortuary Technician Jason Sayers received the ALLIED HEALTH PRACTITIONER AWARD, which attracted a total of seven nominations.Jason manages the day to day activity within the mortuary and is always available to assist families, the police or funeral directors at any time of day or night, ensuring that the deceased and their whanau are treated with the utmost respect during their journey through the mortuary. He was a key player in the recent mortuary upgrade and the recent successful independent IANZ accreditation of the facility.Jason’s reputation for prompt and professional service has increased the post mortem throughput at Rotorua Hospital considerably in the last two years.
13
Scheduler for Elective and Surgical Services, Lynette Ainsworth and Clinical Equipment Pool Co-ordinator Sally Hurihanganui share the NON-CLINICAL SUPPORT AWARD.
Lynette’s service manager says she consistently contributes to the overall goals and objectives of the service, and has been a key player in moving the service forward, including the work she did as part of the Theatre project, the implementation of IPM and the service’s clinical governance framework.
Service manager Jenny Martelli says Sally brought many years of hospital and equipment knowledge to her new role as clinical equipment pool co-ordinator, when it was set up in 2011. She is described as providing excellent customer service. There were five nominations for this award.
The number of Quality Award categories was streamlined from earlier years down to two. Projects entered into either of the two categories had to demonstrate l A degree of research and innovation l Team work or partnership l Consideration of the effects of the project for Maori l Links to providing improved clinical care and/or customer service
The winner of the QUALITY AWARD for a LAKES DHB TEAM OR SERVICE PROJECT was the Pre Operative Assessment Clinic project.The nurse-led Pre Operative Assessment Clinic has been operational for more than a year now. It provides a more patient-focussed service, often able to see patients on the same day as their specialist appointment, and has seen the number of elective day-of-surgery cancellations reduce. Patient access to surgery has been improved because of the ability to address clinical and social issues at a much earlier stage. The informed consent process used by the clinic has allowed the patients to make a decision based on the maximal information available, with the appropriate information provided at many points throughout the patient journey.
The winner of the QUALITY AWARD – for a Lakes district project, in the community was Physician Denise Aitken, with the Cough, Cough, Cough ProjectThe ‘Cough cough cough’ campaign was an awareness campaign about the early detection of lung cancer which took place in Rotorua late in 2010. Rotorua was a good place for the Midland Cancer Network to pilot this project as Lakes DHB has significantly higher lung cancer rates than other areas of New Zealand
14
Patient Safety - Patient Falls Prevention
Aim: To reduce the number of patient falls with harm to zero
Benefits to patients and familiesThe benefits to patients and their families include; l Patients don’t fall and injure themselves during their hospital admission l Patients do go home earlier and recover from their hospital admission quicker
Achievement to dateAll units have an identified falls champion. A new falls risk assessment and care plan has been developed.Falls prevention equipment is available in the equipment store.
Background and rationaleIt is very common within hospital settings to have patients who are at increased risk of falling and who are also at greater risk than normal of suffering harm as a result of a fall. The aim of this programme is to raise awareness of the issue of falls and to promote good practice in falls prevention.
Priorities for the next 12 monthsDevelop a strategy for falls reduction across the community/ primary / secondary / tertiary sectors.Have a collaborative agreement in place by June 2014.
Actual Data Series For the period ending - June 2013 Representing Service: (All) Cost Centre: (All)
Balanced Scorecard Reporting Graph
Clinical Quality - CQ11 - Patient Falls with Harm
15
The following two initiatives support are part of the patient falls prevention programme.
Introduction of a falls champion role to an Acute Medical Unit
Aim: To support the role of the falls champion in the Medical Unit and reduce the falls rate by 25% in 2013.
Benefits to patients and familiesReduction in falls in the Medical Unit by 50% in the first quarter of 2013
Achievements to dateA falls champion was selected in the Medical Unit late November 2012 - a senior registered nurse who was committed to reducing patient falls in the unit.The unit falls champion has:1. Raised staff awareness about falls prevention in the unit2. Commenced a comprehensive unit falls folder 3. Audited patient falls risk assessments 4. Designed a falls stamp for clinical notes – which anecdotally has improved coding accuracy5. Designed a falls analysis spreadsheet to assist with cause and effect issues, and to maximise post incident learning for future falls prevention.
Background and rationaleThe 42-bed acute Medical Unit had the highest rate by far of patient falls in the organisation from January to December 2012 : l 103 falls – 42 with injury mainly contusions, lacerations l 11 near misses
Falls Champion Carol Fisher at the 17 May 2013 launch of the national patient safety campaign.
2011 – first quarter 2012 – first quarter 2013 – first quarter
January 7 falls January 9 falls January 4 falls
February 10 falls February 9 falls February 3 falls
March 5 falls March 6 falls March 5 falls
Total 22 falls Total 24 falls Total 12 falls
16
Red Socks Campaign – An Initiative From the Orthopaedic Unit
Benefits to patients and familiesSpecial red socks keep patients at risk of falling in Rotorua Hospital safely on their feet and get them home safely.Patients participated in the trialling of the socks and provided input into the plan.
Achievements to dateSince their introduction to the Orthopaedic Unit in early 2012 the number of falls has significantly reduced from 39 in 2011 and 37 in 2012 to 18 in 2013.
Background and rationaleOrthopaedic Unit staff wanted to keep their patients safer and protect them from falls when wearing white TED stockings. They chose red socks with special grips fastened to the bottom and trialled them in the last year. The staff felt the colour had to be red to be bright and noticeable; so they could quickly identify who needed most help and give it to them
Heather Schilt, the unit’s Clinical Nurse Manager says: “Patients who are at risk of falling will wear the socks for their entire stay to enable them to get in and out of bed safely, and not worry about having to find their slippers or other footwear.”She says not having to take the socks on or off is really great for patients, especially if they are elderly and find moving around difficult, or if they are a little forgetful. The unit staff thought it would be a fairly simple matter of sourcing the right red socks and having the plastic grips printed on to the bottom, but it was not that easy. In the end, a Levin sock manufacturer worked with the staff, and chose the grips that provided the best grip and coverage on the bottom of the socks.Patients helped trial the first delivery of 50 pairs of socks and provided really useful feedback about what worked, and why.The socks come in small, medium and large and have been available through Stores at around $7 a pair since early 2012, which means they are available to all hospital units. The patient is given a pair of socks and takes them home when they leave hospital.
17
Patient Safety - Safe Sleeping
Safe Sleeping Programme The Pepi Pod
Aim: To provide newborn babies at increased risk of sudden infant death a safe sleeping space and safe sleeping messages to families.
Benefits to patients and familiesThe babies to benefit from pepi-pods are those with a weakened drive to breathe due to smoking in pregnancy, being premature, a low birth weight, formula fed or for some other reason. Such babies have a weakened ‘wake-up’ response relative to other babies. They are slow to detect danger when oxygen levels reduce.
Achievements to dateSince the Pepi Pod programme has been running at Lakes DHB (12 months), approximately 150 pepi pods have been distributed.
Background and rationaleThe picture of SUDI rates at the national and DHB level is based on information taken from the New Zealand Mortality Collection. SUDI is responsible for between 65 and 70 deaths per year on average in New Zealand while noting that, in 2009, there were 102 such cases. However these figures mask significant disparity. In the years 2002-2008 the rate for New Zealand European was 0.52 per 1,000 live births, and the rate for Maori was 2.34 per 1,000 births (4.5 times higher). European countries have rates as low as 0.10 per 1,000 live births (Netherlands).The SUDI rate for the Lakes DHB from 2005-2009 was approximately 1.3 per 1,000 live births. Given that our current live birth numbers are around 1500, we would thus expect there to be, on average, about two deaths from SUDI within the Lakes DHB population per year. However, it should be noted that this is an average figure, and that the actual number of deaths in any one year may be well be higher (or lower) than this.Over the years, health professionals have increased their understanding of SUDI and have identified the key risk factors for babies. These factors include a combination of smoking in pregnancy, inappropriate sleeping practices and not breast-feeding. While Lakes DHB has placed significant resource on addressing smoking in pregnancy and increasing breastfeeding rates, minimal attention and focus had been placed on safe sleeping environments for vulnerable babies. Pepi-pods are not for all babies. They are a public health solution to the increased risk of sudden infant death for certain babies in certain conditions. The babies to benefit from pepi-pods are those with a weakened drive to breathe due to smoking in pregnancy, being premature, a low birth weight, formula fed or for some other reason.
18
Patient Safety - VTE Prevention
VTE Prevention Programme
Aim: Aiming for zero patient harm l To prevent life threatening Venous Thromboembolism (VTE) in all hospitalised patients over 18 years and pregnant teenagers l To minimise avoidable disability and chronic ill health from hospital-associated VTE l To minimise avoidable death from pulmonary embolism (PE)
Benefits to patients and familiesContinually making patients safer by applying individualised risk assessment, prevention measures and involving patients in managing their own care. l Education of patients and their partners on VTE risks and prevention measures has empowered patients to request the appropriate prophylaxis and supported them e.g. to (self-)administer subcutaneous heparin injections for an extended period at home. l Patients identified as high risk benefit from additional prevention measures l Early mobilisation and hydration is shown to reduce VTE events
Achievements to dateWe launched the programme in July 2011 and have since then conducted audits every two months to assess the performance against our best practice standards. We also recorded the number of hospital-associated VTE events to see whether we have improved patient outcomes and in order to feed back to the clinical teams.We were working towards a 100% compliance rate with routine VTE risk assessment within 24 hours of admission to hospital and 100% compliance with providing appropriate, evidence-informed thromboprophylaxis. We have achieved an amazing uptake of ‘best practice’ which is starting to translate in less VTE events and patient harm.
Year End Achievement (June 2013)
Obstetrics: 100%Medicine: 100%Orthopaedics: 84%Surgical: 80%
Amazing trends in % uptake of appropriate VTE prevention
19
Background and rationaleVTE is the commonest potentially preventable cause of hospital-related morbidity and mortality. The risk of developing VTE increases tenfold in patients admitted to hospital versus non-hospitalised people. About 10% of all patients experiencing a PE will die as a result of it. Morbidity from VTE for survivors and the resulting costs to the health care system can be substantial.Once a patient has suffered a deep vein thrombosis (DVT) or PE, the risk of recurrence or death is greatly increased. Therefore VTE prevention in hospitalised patients is internationally recognised as a major opportunity to improve patient safety.Baseline audits at Lakes DHB showed a poor compliance with VTE prevention guidelines, especially for medical and orthopaedic patients.
Baseline compliance prior to VTE Prevention Scheme (June 2011)
Obstetrics: 80% Surgery: 78% Medicine: 40% Orthopaedics: 35%
To address the variable, unsafe approach to VTE prevention, we updated our VTE Prevention Guidelines for medical, surgical, orthopaedic and obstetric patients. In order to ensure the appropriate VTE prophylaxis was provided for individual patients, we developed VTE risk assessment tools to guide the therapy.
Priorities for the next 12 months l Sustain and improve our current results l Focus on trauma patients and ways to prevent VTE events in this patient group l Measure the possible side effects of effective thromboprophylaxis (such as bleeding events) – perform a risk/benefit analysis l Consider the withdrawal of TED stockings as mechanical thromboprophylaxis measure and only apply intermittent calf compressors to patients at high VTE risk and/or with contraindications to chemical prophylaxis.
Dr Ulrike Buehner and Lesley Everest
Margaret who has had a number of visits to the
Surgical Unit says:“I would like to sincerely thank the nursing staff for the interest and dedicated care given
to each ‘stubborn’ wound(s) during my often lengthy hospital visits. As a patient I felt comfortable and safe with the nurses who
managed the treatment and cared for me. This makes such a difference to the patient’s
spirit, wellbeing and recovery.”
20
Patient Safety and Clinical Effectiveness
Lakes DHB Research and Ethics Committee
Aim: The Lakes DHB Research and Ethics Committee was set up to encourage and facilitate an innovative research culture within Lakes DHB. The committee ensures that all research undertaken involving Lakes DHB patients or resources has the appropriate approval, is sound and undertaken by researchers with relevant qualification and skill. The committee also provides an accessible forum to discuss matters of ethical concern.
Benefits to patients and familiesPatients and their families can be assured that if they are participating in a research project they will be fully informed and that there has been consumer input into approval of the research.
Achievements to date l A register of all research being carried out at Lakes DHB is kept by the Research and Ethics Committee as reference point for other researchers and to track research to the point of completion l The Lakes DHB Research and Ethics Committee holds a health research seminar in November every year. Invitations are sent to a wide cross section of the community to attend and present at the seminar, which is usually widely supported. l Researchers in the Lakes district are able to network and discuss issues of relevance to them and the Lakes population l Staff have had the opportunity to present and discuss their research to a forum of researchers, to network with health researchers and those interested in research across the district and to be familiar with other researchers’ work l The committee meets monthly and has dealt with a number of research submissions from various individuals and organisations l The committee has established itself as a valuable resource for staff to discuss and be advised on research and ethical queries l The committee is beginning to receive for its consideration matters pertaining to clinical ethics as distinct from research ethics l The committee membership includes representation from: primary care, secondary care, nursing, the community and Maori health, along with three community representatives. l Maori input to all research applications registered with the Lakes REC is ensured l The Chair of REC is a member of the Health Research Council Ethics Committee (HRCEC) and the Advisory Committee on Assisted Reproductive Technology (ACART). l The Chair was part of a group which has developed a Maori ethical framework called, “Te Ara Tika” in partnership with the National Ethics Advisory Committee (NEAC) and the Health Research Council and Nga Pae o Maramatanga at the University of Auckland. This was published by the Health Research Council in 2010 l There has been growing interest from other DHBs in the Lakes DHB Research and Ethics Committee and the committee’s terms of reference have been shared with the Midland DHBs.
Background and rationaleThe Research and Ethics Committee at Lakes DHB acts as a central body for co-ordinating research projects and provides assurance to the organisation and public that all research carried out at Lakes is ethically safe, relevant and quality work.A terms of reference document that guides the governance of research and research policy is reviewed regularly. The policy is consistent with national legislation, the Health Research Council of New Zealand (HRC) statements and the Code of Health and Disability Services Consumers’ Rights.
21
Patient Safety and Integration
Vulnerable Unborns
Aim: The purpose of the programme is: l To identify vulnerable unborn babies l Share and gather information – no information to be held in isolation. l Identify the women’s/families’ ability to engage with support agencies l Liaise with midwifery practitioners as the pregnancy progresses l Clarify support needs l Generate an individualised ongoing plan l Develop a safety plan in high risk cases l Escalate the risks and work with the Child Youth and Family Service to implement a high level response, which could result in uplifting the baby at birth.
Benefits to patients and familiesBabies in the programme have a plan of care that includes support services and education for the mother and family.
Achievements to dateAll the babies in the programme have a plan of care which identifies the support services for the mother and family. Included in the programme is ensuring comprehensive education is provided to the mother/whanau on a smoking cessation programme completed, safe sleeping, pepi pod provided if at risk and the Shaken Baby Programme covered prior to discharge. Dr Johan Morreau Community Paediatrician believes this initiative is ‘gaining momentum’. It will in time, and as long as the health and welfare systems are sufficiently responsive, facilitate the most important health intervention, namely “supporting parents to parent” that we can offer to our families. This will then have a significant impact on the health and wellbeing of 10-20% of our children.
As word of the vulnerable unborn work at Lakes DHB has spread, the coordinator Sarah McMillan has been on several occasions requested to present nationally on the model and share the model with other DHBs.
Background and rationaleIn 2009, a baby died following a family violence episode. On reviewing the case it was evident that the different agencies involved with this family were not aware of continuing violence. Additionally, those agencies with some knowledge of the family had not shared that information with other agencies with an interest in the child and mother. The mother was offered referral to support services but had declined hence no additional follow-up occurred and the vulnerability issues of
the unborn were not addressed. This tragic event raised awareness of the importance of recognising unborn babies that are at risk, taking a collaborative approach and developing a framework for the activities of the group. The number of referrals to the Child Protection Coordinator from Police Family Violence, Family Start, midwives, CYF, the Youth Health Service, and primary care increased markedly following this event. Many of these were new referral sources. The concerns were predominantly around family violence, alcohol and drug use, non-
22
engagement in antenatal care and concerns for the unborn baby. This led to the DHB investigating how best to manage the referrals and attempts to establish how other DHBs managed such risks. This work highlighted the fact there seemed to be no existing initiatives in place.
Priority for the next 12 monthsDevelopment of this group is continuing with groups now established in both Taupo/Turangi and Rotorua. It has informed the early development of a vulnerable under-fives group.With the actioning of the Children’s Action Plans in Rotorua the vulnerable unborns group will align with this programme.
23
Patient Safety and Integration
Lakes Heart Health Group
Aim: Improving outcomes for Lakes DHB people with cardiac disease.
Benefits to patients and families l Patients presenting with heart pain will have their cardiac risk assessed early and receive faster more appropriate care. l Their care will always be checked against agreed standards and if there is a problem it will be addressed. l The problem of long wait times for cardiac surgery whilst waiting for dental care has been fixed. l Patients have been involved in planning the service for heart failure via a series of interviews.
Achievements to date 1. A newly introduced chest pain road map. l Current baseline management of Acute Coronary Syndrome (ACS) requires that the patient starts in the emergency department with the newly introduced chest pain pathway. Further care is based on the use of the regionally approved risk management scoring tool TIMI, used together with the Midland Region ACS treatment algorithm.2. Lakes Heart Health (LHH) implementation of continuous audit. l The LHH Project received MoH support for introduction and implementation of the ANZACS-QI software programme l This has been successfully achieved. l Lakes is meeting the new national target of 95% completion of the ANZACS-QI data of ACS patient admitted at 97% l The visibility of outcomes from this audit data has driven improvements in care via better adherence to agreed protocol and ongoing review of practiceANZACS – QI data shows that only 48.3% of high risk ACS patients at Lakes have received cardiac angiography within three days over the last nine months. l This is a focus of attention from Lakes and Waikato DHBs and tracking the data has seen improvement in performance in this time to investigation target l Current data shows performance against the Midland Cardiac Network 2012/2013 Work Programme outcome measures
90 % of ACS patients receiving a risk assessment and classification within 24 hours of presentingAchieved
80 % of patients requiring referral to Waikato Hospital for angiography will be referred the day of admission. Achieved
70 % of high risk ACS patients receiving angiograms within 3 days of presentingNot achieved
90 % of non high risk ACS patients undergoing further risk stratification tests within 72 hours of presenting Achieved
24
3. A business case has been developed to expand the cardiac nurse specialist role to include specific ACS initiatives. This, together with ANZACS-QI information supports the establishment of nurse-led clinics. This has been demonstrated elsewhere to l significantly reduce outpatient waiting times across cardiology l improve management process for patients Ø this objective is currently being worked towards.4. Lakes Heart Health supported employment of a summer student who worked with chronic heart failure patients, both to audit their clinical features and to record their satisfaction and experience with the service. The information gained supported establishment of a heart failure service in the Lakes region but also validated the role of nurse practitioners in Turangi and Mangakino.As a result of this work the objective of a heart failure service has been identified with cost benefit in terms of avoided admissions. This project is currently being worked on.
Background and rationaleThe Lakes Heart Health Project (LHHP) Group was formed in 2011 with input from Professor Norman Sharpe, Chair NZ Heart Foundation. It is a cross sector group including ambulance, primary care, emergency medicine, general medicine and cardiology and includes nurses and doctors. It has the aim of improving all outcomes for people with cardiac disease in Lakes district. This was against a background of lower access to cardiac interventions than the national average in a region where health needs were higher than the national average. Since then the Midland region has initiated a region wide service improvement project in cardiology which is delivering better care across the region. LHHP is working with this project.
Priorities for the next 12 monthsEstablishing nurse led clinics in ACS and heart failure.Patient representation on Lakes Heart Health Group.
”Quality covers the complete service delivery of health care where all
departments are committed to meeting the needs of the patients.”
Lesley Yule, Quality & Risk Manager
“I don’t think Icould evermanageon my own”
Better facilitatetransitionary care
Setindividualisedcaremanagementplans
Recognise support structures
Deliverpatient-specific healtheducation
“They say you gota heart failure soyou got heartfailure”
“I do exactlywhat they say”
Strictadherence butlimited healthliteracy
Heartfailurenursespecialistrole
Adopt acollaborativemultidisciplinaryapproach
25
Patient Experience
Mirimiri for Patient Comfort
Aim: To improve perceived comfort level and reduce miscellaneous pain during haemodialysis treatments.
Benefits to patients and familiesMirimiri has benefited patients having renal dialysis by bestowing comfort during the long treatment process. Furthermore, patients have been able to embrace their culture and traditional customs within a supportive environment. After treatment patients have a general improvement in well being and enjoyment of life.
Achievements to dateThe mirimiri practitioner visits the unit four sessions per week, providing two sessions per patient group. She works with all patients who request her service. The patients appreciate the extra care provided, and have reported to feel better in themselves and more relaxed in their unit environment. Some have reported improved pain and mobility.
Background and rationale Haemodialysis is a thrice weekly treatment that patients attend for an indefinite timeframe. Patients requiring this treatment often have other chronic morbid conditions and feel generally unwell, lack energy and stamina. They also have low – medium levels of pain and are at increased risk of infection. Increasing comfort during treatment can help their tolerance of treatment, improve their quality of life, and reduce their stress Two unit registered nurses chose to investigate the introduction of mirimiri into the unit as a project for a course they were undertaking. They researched options, sourced practitioners, talked to the patients about their requests and thoughts, liaised with a small number of potential practitioners and introduced them to the service and treatment we provide. The nurses liaised with Hunga Manaaki when they recommended a practitioner and helped them to instigate the service .
Priorities for the next 12 months l To embed the service. l Present the project at an international conference, and to formally audit patient response to service provided.
26
Patient Experience
Whanau Room
Aim: To provide patients and whanau with a non clinical setting within the outpatient department.
Benefits to patients and familiesPatients and their support/whanau have a private place to go when they are upset, have restless children or just generally need a quiet space.
Achievements to dateThe room is now complete and currently utilised for l Patients requiring additional support when given ‘bad news’ l Support for both patient and whanau within oncology clinics l Meetings with consultant and whanau l Mothers with babies / young children l Significant waiting time for mothers, older adults and patients in need
Background and rationale The outpatient team observed that there was a need for a private space for patients and their support people at times. While the consulting rooms are private it is often before or after seeing the doctor that a more private space is needed. The outpatient nurses in their performance appraisals identified the growing need for a whanau room within the outpatient setting.What began as an under utilised storeroom has been transformed into a beautiful, well-designed whanau room. The room was initially transformed by Facilities Department staff, furnished by the Ambulatory Service staff and then decorated by the Breast Cancer Society.
27
Patient Experience
An improved service delivery for skin cancers of the head and neck
Aim: To improve the flow pathway for patients with complex head and neck skin cancers.
Benefits to patients and familiesPatients are being seen sooner by a specialist for assessment and having their surgical procedure sooner. Some patients can have their assessment and surgery locally, saving their time, money and time off work for the family and whanau.
Achievements to datePatients referred by their GP to Ear, Nose & Throat (ENT) were seen in a timely manner compliant with national recommendations. l The waiting times for the patients to be seen in the ENT clinics was reduced by 43%. l The waiting times for surgery also reduced by 77%. l General surgery referrals to ENT pathway reduced the waiting times from specialist clinics to theatre by 71%.Currently, the extra workload diverted into the ENT specialty is absorbed without any significant impact. The ENT surgeons are managing clinic waiting times efficiently and the current waiting time for a routine ENT clinic appointment is around two months. The savings made for operating on each patient at Lakes DHB instead of Waikato Hospital can range from $2000 to $5000. Over a period of a year the cost savings are significant.
Background and rationale Complex head and neck skin cancer patients were being referred to the plastic surgeons (from Waikato Hospital) by GPs or general surgeons. The plastic surgeons have one clinic a month at Lakes DHB, subject to availability. If the patients require surgery they will have to go to Waikato Hospital for it. The clinic waiting times did not always meet the standards set by the Canterbury Initiatives. Patients managed by the plastic surgeons have to travel to Waikato Hospital for surgery. This referral pathway was changed to referring directly to ENT surgeon Christopher Low, who manages the same conditions and operates at Lakes DHB instead. Dr Low presented at a local GP business meeting to instigate the change. He also engaged with the general surgeons to make this pathway change possible.
Joseph who spent time at both Rotorua and Waikato Hospitals comments:
“The care and attention I received from surgeon, specialists, nurses, nurse aides and attendants during my time in both hospitals was,
to say the least, exemplary. The team work was excellent with no one group trying to outdo
the others….”
28
Patient Experience
Buckeye Meal System
Aim: To improve the patient food service by delivering the correct meal to the patient in the correct place.
Benefits to patients and familiesPatients receive the meal they have ordered, or a meal appropriate to their dietary requirements in cases of specialised dietary needs.
Achievements to dateThe ‘Buckeye’ meal system was installed in December 2012 and has been running for six months at Rotorua Hospital. It is linked to the patient management system which shows where the patient is located. Since implementation there have been fewer occurrences of patients not receiving the meal they have ordered. The system has also meant that the appropriate meal order is delivered when patients move from unit to unit. Another benefit has been the marked decrease in meals being delivered to the hospital units after patients have been discharged, resulting in considerable savings to the DHB.
Background and rationale A Spotless Services Limited integrated food management software product called ‘Buckeye’ provides a menu management system and enables nutrient analysis, food production control and account and inventory management. ‘Buckeye’ integrates with the Patient Master Index of our Patient Management System. The patient’s admission time and location are used in association with a captured “diet code” to assign them a meal according to their diet type.
Unit staff update the Patient Management System as patient location or diet requirements change. This information is picked up three times a day and merged into ‘Buckeye’, enabling the most up to date information for meal times.
29
Patient Experience and Clinical Effectiveness
Improving referral pathway to mobile ear clinic services
Aim: To streamline the process for using the mobile ear clinic services.
Benefits to patients and familiesChildren who need to be assessed by the mobile ear service get seen quicker.
Achievements to dateThe ENT surgeons, together with the mobile ear clinic staff, reviewed the current referral process and worked together on improving the existing referral criteria and pathways.The surgeons also worked with the staff to develop a training programme that will upskill their practice and knowledge.The referral criteria and guidelines assist the staff to screen the referrals and to return those that are inappropriate.A pathway for ear infections supports the staff to know what treatment is required and who to refer on to.The streamlining of the process also ensures that appropriate referrals are made to the ENT service and therefore assists in reducing waiting times for both services.
Background and rationale The mobile ear clinic service was becoming overwhelmed by the number of self-referrals for assessment and advice. The primary purpose of the service is to screen children for ear disease, support ongoing surveillance for ear disease and manage simple ear infections and foreign bodies. However the service has had patients with ear wax or hearing loss which is an inappropriate utilisation of staff expertise. Such patients should see their GP.
30
Patient Experience and Clinical Effectiveness
Endoscopy at Lakes DHB
Aim: To provide the safest, highest quality endoscopy service and be recognised nationally amongst the top performing endoscopy units.
Benefits to patients and familiesWe are measuring and focusing on improving in four key areas. These are: l Delivering the best quality and safest endoscopy service l Customer care - quality of patient experience l Improving the knowledge and training of workforce l Working together as team to do this.
Achievements to date1. Raising the profile of endoscopy within our DHB2. Rolling audits of specific key performance indicators (caecal intubation rate, adenomatous polyp detection rate and patient comfort).3. Patient and staff surveys via questionnaires4. Adverse event recording and feedback, from consent to all complications.5. Focused training6. Improved efficiency through: productivity tools, pooled lists and pathway documentation. 7. Users group meetings monthly, with wide range of representation8. Introduction of post-procedure information leaflets and improvement of pre-procedure information leaflets.9. Identification of main limiting factor in development: an electronic reporting system to communicate results promptly and accurately. 10. Through all these improvements Lakes DHB is well positioned to be one of the first centres in New Zealand to be accredited as a bowel cancer screening unit.
Background and rationale In 2011 Lakes DHB’s application was successful and Lakes became one of four pilot sites to implement the GRS (Global Rating Scale), a UK developed tool that enables units to assess how well they provide a patient-centered endoscopy service. GRS is a web-based assessment tool that makes a series of statements requiring a yes or no answer. From the answers the system automatically calculates the GRS scores.
Priority for the next 12 monthsTo gain accreditation to become one of the first bowel cancer screening units in New Zealand.
Fig 1 July 2011 Fig 2 April 2013
31
Patient Safety and Clinical Effectiveness
Simulation Unit
Aim: The aim of simulation-based education is to improve the quality of teaching for clinical staff and improve patient safety at reasonable cost. Residents’ work conditions, ongoing training and credentialing are also contributors towards the use of simulation-based education (SBE).
Benefits to patients and familiesSimulation-based education improves the skills of midwives, nurses and doctors and allows them to practice teamwork in a learning situation so that when these skills and teamwork are required in a clinical situation they are well rehearsed. This means that in real emergency situations with patients the multi-disciplinary team works smoothly with everyone knowing their roles.
Achievements to date l A commitment to the provision of high-quality simulation-based education (SBE) within Lakes DHB exists. l A committee was formed to give guidance to decisions regarding SBE. l A stock-take of current simulation-based training courses, in which Lakes employees (and related groups) are involved and of current equipment was carried out. l A new, more modern and spacious clinical training room has been set up for SBE, including a control room for supervisors to watch trainees and control what the manikins are doing. l Team members have visited six different simulation units (hospital and other sites in Auckland, Wellington and Hamilton) to assess equipment needs. l A plan regarding financial issues and priorities is underway. l A priority list for new equipment and facility development was agreed on. l In order to determine the necessary resource implications, the time required for staff to run and administer current courses was assessed as well as the time utilised by staff to attend these courses. l The planned clinical training area was also reviewed. l A plan was made regarding future SBE-related courses, including the plan for a Lakes DHB simulation- based course, focusing on team work, communication skills in a crisis.
Locally-run, nationally recognised courses l There are a number of courses currently run within the DHB, which involve significant amounts of SBE. These include the following: l ACLS (Advanced Cardiac Life Support) – two days long, six per year l ACLS – one-day update – five per year l Basic CPR course – 14 days a year (each day three by two-hour sessions) l Level IV ACLS Course – nine per year l PLS (Paediatric Life Support) one-day by four per year (three involve 12 candidates, one involves 24 and is a regional course run with BOP DHB) l NLS (Newborn Life Support) – about five per year l PROMPT (Practical Obstetric Multi-Professional Training) l ACT (Acute Care Training) Course – four per year l The Department of Paediatrics is instituting regular “Scenario Teaching” sessions fortnightly, aimed at improving and reinforcing emergency skills for the SHOs also attended by students. l Other departments have simulation-based teaching
32
Background and rationaleLakes DHB is becoming more involved with training medical students (University of Auckland), nurses (Waiariki Institute of Technology), midwives (Auckland University of Technology and Wintec) and other professionals. The organisation also has a responsibility to ensure that employees maintain a high standard of education in relation to emergency and other situations. Training and resources need to match the increased demand, be up to date and contemporary.Simulation-based education (SBE) is now a vital component of teaching, providing a cost-effective means of safely educating clinicians from multiple specialties. Simulation in the context of medical education aims to imitate real patients, anatomic regions, or clinical tasks, and/or to mirror the real- life circumstances in which medical services are rendered.
Priorities for the next 12 months l Continue to build up the equipment required for the simulation unit as funding allows. l Continue to develop the courses. l Consideration about the role of “in-situ” teaching still needs development.
33
Clinical Effectiveness
Closed Chemotherapy Administration System
Aim: The aim of the initiative was to reduce the risk of exposure to cytotoxic droplets for both patients and staff during the administration of chemotherapy.
Benefits to patients and familiesThis initiative has reduced the risk of accidental exposure to cytotoxics by 85% for both patients and the nursing staff.
Achievements to date A proposal was prepared by the chemotherapy team leader and the IV nurse specialist. A new closed system allowing for multiple bags to be attached was implemented. This saved the need to disconnect and reconnect each bag. The entire system is disposed off when the treatment has been completed. The chemotherapy unit piloted the system in November 2012, initial problems were sorted with the manufacturer and the system went live early in 2013. The Lakes DHB Chemotherapy Unit administers approximately 140 treatments a month and this number continues to grow.
Background and rationaleChemotherapy drugs are highly toxic which can mean that patients and staff are at risk of exposure to droplets and spills during the connection and disconnection of the intravenous administration systems.The administration of intravenous chemotherapy is a specialised role for nurses who are trained in minimising the risk of exposure to the cytotoxic drugs, however the more handling of the infusion bags containing the drug the more risk there is of droplet spray. The chemotherapy regimes are increasingly complex with multidrug regimes being administered at the one time. Between each drug the intravenous line needs to be flushed with normal saline to remove any drug residue. Each time the line is accessed the risk increases.Technology continues to improve with the development of equipment that reduces the need to connect and disconnect the various drug bags.
34
Clinical Effectiveness
Introducing Txt reminders for specialist outpatient appointments project
Aim: To improve the accessibility and flexibility of outpatient appointments for all patients, with a special focus on children so that they can access care they need.
Benefits to patients and familiesPatients receive additional reminders to attend their specialist appointment via an automated “cell phone texting system”. They are also able to notify the outpatient department about a cancellation of their appointment and can let the service know if they are likely to have difficulties in attending because of transport or other reasons.Using all outpatient opportunities is better for everyone; patients and staff; people get the heath care they need and wait less time.
Achievements to dateThe Ambulatory Centre, Outpatients Department for specialist appointments adopted the automated txt system for reminding patients of their scheduled specialist outpatient appointment. Patients now receive a txt reminder five days and one day prior to appointment and are given the option to reply if they are unable to attend. If a patient is not able to receive a txt message they continue to be called by the hospital telephonists the afternoon prior to appointment.
The initiative has meant that patients are supported and early notification by patients who are not able to attend the appointment allows for that appointment time to be given to other patients who require an urgent consultation, reducing their waiting as well as emergency department presentations and inpatient admissions.
Although txt reminders has made a positive impact on reducing patients who do not attend specialist appointments there was other work needed that has been achieved. This is part of a positive culture of seeing the outpatient department as being supportive of patients attending.
l The staff have put a particular focus on children who are reliant on a parent or guardian to bring them to specialist appointments. Children who frequently are not brought to consecutive appointments are considered to be high risk. l The outpatient staff continue to try and make phone contact with patients who do not attend appointments. l If contact is unable to be made the staff will then check with the GP for any updates in address and/ or telephone numbers. l The outpatient manager is informed of patients who are unable to be reached despite all efforts to pursue. Community organisations are sought for assistance e.g. Public Health, GP, social worker and most importantly for children, Well Child provider. l All txt responses are followed up so that another appointment time can be allocated if still required. l A second appointment is not offered until contact has been made with the patient or care-giver.
35
Background and rationaleThere has been an increasing trend in 2010 to 2012 in the percentage of patients that did not attend their specialist appointments. More concerning is that a large proportion of these were children. The outpatient department staff were sending reminder letters and arranging for patients to be phoned the day before the appointment. However the rate continued to rise with some clinics showing higher rates than others. All non-attendees were sent another appointment. Among the reasons for not attending clinics are: l People simply forget the appointments and at times their health is not a priority l The patient believes their appointment is no longer required as his or her condition has improved l Contact details are incorrect when people have moved house, changed phone number and GP. l Date and time of appointment didn’t suit l Transport difficulties
Priorities for the next 12 monthsThe aim for the next 12 months is to reduce the non-attendance rate to 6% for all specialist clinics. The following initiatives will assist in achieving this target; l A patient information brochure is being developed by the team and will be available in primary care. This will inform patients of the referral process, contact phone numbers, eligibility, transport options and other important information. l The Talipes (clubfoot) clinic which is held every second Friday, plans to have a Maori representative (Hunga Manaaki) support to assist whanau. The clinic is predominantly for babies and toddlers who require early treatment to reduce the possibility of long term deformity, and tends to have a high non-attendance rate. l Identifying and using the child’s Well Child provider which has offered to assist in bringing children to clinic if there is a concern and the child is at risk of not presenting.
Actual Data Series For the period ending - June 2013 Representing Service: (All) Cost Centre: (All)
Balanced Scorecard Reporting Graph
Productivity - PP07 - DNA Rate - % failed to attend outpatient appointments
36
Clinical Effectiveness
Clinical Handover
Aim: To provide a common language between health professionals to ensure consistency, and thus safety.
Benefits to patients and familiesTo ensure that patient care is handed over between health professionals and patients don’t fall between the cracks in the system.
Achievements to dateA project group was set up with Dr Stephen Bradley as the clinical leader. The other leaders of the project team are Christine Payne, Clinical Nurse Director and Lesley Yule, Manager, Quality and Risk.
The project focused on the individual handover using an international standard tool. Lakes DHB’s Clinical Governance Committee agreed to implement the use of the SBARR to provide the common language for handover.
This is l Situation; l Background; l Assessment; l Recommendation; l Response;
A teaching session, developed by Dr Bradley has been piloted in the paediatric and obstetric/maternity service. The teaching package includes a video illustrating how to use the SBARR tool. The next steps are to roll out SBARR for individual handovers within other services.
Background and rationaleClinical handover is described as “The transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis”. With the increasing complexity for patient care, shorter hospital stays and more professionals involved in patient-care, the need to have a more structured process of handover has increased. For example, a recent study at Auckland Hospital demonstrated that, on average, a medical patient may have contact with at least 18 professionals during their hospital stay and a surgical patient contact with 27 professionals.
“It is great to see so many initiatives that have benefits to and are
improving care for children and their families. These are vitally important for improving outcomes and ensuring that quality is part
of all we do.” Dr Stephen Bradley, Clinical Director
Woman, Child & Family Service
37
A key issue is to make sure that patients don’t fall between the cracks in the system. The two levels of handover are: l Individual patient handover between individual professionals l Groups of patients being handed over to an individual or group of professionals.
Team handovers are well used in most services. This usually involves a team meeting at change of shift with all patients discussed and plans for the next 24 hours agreed. Further work regarding team handovers will follow implementation of the SBARR programme for individual handovers.
Priority for the next 12 monthsRoll out to across the organisation will require further resourcing and project support.
38
Clinical Effectiveness and Integration
Trauma Care Quality Improvement Programme
Aim: To ensure best practice in trauma care to patients and their families along the journey from point of injury to optimal function.
Benefits to patients and families l All patients receive optimal trauma care at the right time in the right place and delivered by the right people (multi- disciplinary team approach) l The patient experiences less delays and complications, more timely rehabilitation and discharge home because of stabilisation, damage control and definitive care l Excellent patient experience and support to whanau
Achievements to date l Trauma specialist nurse, Cherry Campbell, and Consultant, Dr Ulrike Buehner, are working together to support/advise patients and liaise with their clinical teams to ensure all their trauma needs are met. l A multi-disciplinary trauma committee with representatives from St John, Intensive Care Unit, the emergency department, radiology, general surgery, orthopaedics, paediatrics, the Blood Transfusion Service and theatre work on developing an excellent trauma service within the clinical network structure of regional trauma centres. l A monthly review of seriously injured trauma patients has lead to further quality improvement projects: e.g. development of a rib fracture pathway whereby patients with multiple rib fractures are risk- assessed according to a validated scoring system to receive the most appropriate treatment path, e.g. referral to the acute pain service and admission to the Intensive Care Unit. It also led to auditing of key quality indicators (such as timely antibiotic prophylaxis, appropriate venous thromboembolism (VTE) prophylaxis, brain function assessment, trauma call for major and polytrauma patients). l The introduction of a Massive Transfusion Protocol where blood and clotting factors are given in a standardised way for the management of life-threatening haemorrhage in severe trauma has been life-saving and time-critical to good trauma outcomes.
Background and rationaleLakes DHB serves a population of around 100,000 with 7% major trauma cases with an average of five major trauma per month and ~ 66 minor traumas per month.In order to deliver excellent trauma care consistently to all patients who suffer traumatic injuries within our catchment area, we needed to adopt a systematic approach to trauma care and put pathways in place to achieve timely treatment in the most appropriate facility.For this reason, we formed the Midland Regional Trauma System (MRTS) in March 2010, comprising the four Midland DHBs (Waikato, Bay of Plenty, Lakes and Taranaki). Through close collaboration (teleconferences/
39
workshops, trauma committee meetings) we developed local and regional trauma guidelines, an inter-hospital transfer agreement, and defined each DHB’s trauma capability and capacity. The rationale behind it is to streamline the transfer process of trauma patients and to provide easy access to the most appropriate facility, which can safely provide trauma assessment/stabilisation and/or definitive trauma care to our patients.
Priorities for the next 12 months l Working towards Trauma Centre Accreditation (level III) l Monthly mortality & morbidity reviews of major trauma cases will produce learning/action points and be addressed to achieve satisfactory loop closure. l Continuous monitoring of key trauma performance indicators will track improvements made. l Aiming for bi-monthly mock trauma calls to test the system and enhance multi-disciplinary team work, giving time for debrief and learning/action points that may require change in clinical practice.
40
Clinical Effectiveness and Workforce
Paediatric E-Learning
Aim: To support the orientation of resident medical staff into the paediatric department.
Benefits to patients and familiesThe children and their families benefit by having well trained staff taking care of them.
Achievements to dateThe paediatric orientation programme for the resident medical staff is now set up in the e-learning web site. The doctor is invited to introduce themselves to the team and can learn all about the paediatric team at Lakes DHB.There are currently five clinical modules to work through, each of which is blended with a face-to-face teaching session.The modules provide a case scenario where the student makes an assessment based on the history given and explores the treatment options. This is then followed by the more formal teaching session that allows the clinical discussion to take place.The modules are supported by links to references (and web-sites) as well as videos that demonstrate the staff undertaking a procedure.
Background and rationaleResident doctors have a lot to learn when they first work within hospitals and working with children is different to working with adults. Although they have learnt the theory and observed care, the next steps to making decisions about care can be daunting. All the Lakes DHB paediatricians are supportive and work with their residents, teaching sessions are well-structured but taking in new information in a busy work environment is not always easy.Dr Stephen Bradley and Dr Danny de Lore are passionate and committed to teaching, not only the junior medical staff but also nurses and allied staff. They believe that children and their families need the best care possible and are exploring ways to make teaching accessible, as well as fun and meaningful. The Midland region has made available the use of the ‘Moodle” e-learning tool with a web access and training in the use of the tool.Dr Bradley and Dr de Lore are leading Lakes DHB in the use of e-learning for resident medical staff.
Priority for the next 12 monthsOngoing completion of some of the modules.
41
Clinical Effectiveness
Improvement in changing sterility method of nasendoscopes
Aim: To improve the sterilising process for the nasendoscopes in the ENT clinics.
Benefits to patients and familiesWaiting times during the clinic are reduced and patients are seen on time and have the examination at that time, which is more convenient for them. It also communicates the outpatients department’s desire to deliver patient focused care.
Achievements to dateThe ENT outpatient service has changed the method for sterilising the endoscopes from using the Soluscope system to using Chlorine Dioxide (CD) based wipes. This change has resulted in; l Increase through put in sterilising nasendoscope l Reduced delays for waiting for endoscopes to be sterilised l Achieved significant cost savings for Lakes DHB l Improved staff satisfaction with this sterilisation methodThe Chlorine Dioxide (Tristel) wipes cleaning solution is simple and less complicated to use which improves the staff satisfaction. It has already been implemented in our department and will have significant cost savings for the future. Our turn around time for using the endoscopes is much quicker and the quality of patient care has improved.
Background and rationaleNo significant clinic difference has been found as yet with sterilisation methods for non-channelled endoscopes with regards to eradication or organisms or prions (ENT-UK document). Chlorine Dioxide (CD) based wipes has demonstrated adequate efficacy in comparison to Soluscope 3PA (machine-based) which we currently use. Furthermore, CD is quick (five minutes) and Soluscope takes 30-45 minutes for each wash. A cost comparison was undertaken. This was followed by implementation of the CD as our new sterilisation method for endoscope. Cost savings were evaluated, and found to be very positive.
Gordon who needed to be admitted during a visit to
Rotorua states: “I wish to comment on wonderful caring and
prompt treatment I received from all staff during my stay at Rotorua Hospital. The medical
staff were outstanding. All cheerful, caring and wonderful attitudes to their work. The meals
were excellent and the cup of tea/coffee, always a welcome smile and ‘Hello’ from the
lady…”
42
Integration
Primary Care: The Rotorua GP Group (RGPG) has a comprehensive quality programme that supports the Health Targets as well as other patient care initiatives.
Best Practice Support for Primary Care Programme:
Aim: The Best Practice Support for Primary Care Programme requires multi-stage implementation and coordination across a variety of clinical programmes, community based initiatives, and chronic disease management programmes in general practice. This programme supports, leads, and seeks collaboration with all Rotorua Area Primary Health Services (RAPHS) general practices, and Korowai Aroha and Te Runanga o Ngati Pikiao.
Benefits to patients and familiesThe best practice support programme has a number of innovations that are improving care for patients and their families and include early detection and support for diabetes, cardiovascular disease, rheumatic fever and chronic kidney disease.The clinical leadership and professional development ensures that the staff are kept up to date on changes to care and systems and thereby able to provide contemporary care to their patients.
Achievements to date ( end of March 2013)l Clinical Leadership – Clinical leadership is provided for this programme. This is supported by the monthly Clinical Leaders’ Group meetings. l Information Systems – Continuous development, configuration and implementation of IT tools occurs, with on-going training and support for all users including practice staff. The RGPG Technology Team is accessible to all Health Rotorua PHO members for IT support, education, and training. Services are available Monday to Friday 7.30 am to 5.30 pm.l Newborn Enrolment – A local initiative between RGPG and Lakes DHB to automatically enrol all newborns delivered at Rotorua Hospital commenced in September 2012. This has contributed to the pleasing immunisation coverage rates for infants aged eight months. Some 91 per cent of non-high need infants are fully vaccinated by eight months and 85 per cent high need infants. It is expected that this enhanced enrolment process will continue to assist in more timely vaccination of our high need children.l Family Violence – Ongoing education sessions for practice staff commenced this quarter. To date, two sessions have been held with practice nurses. RAPHS clinical leaders have given their support to coding vulnerable children in their PMS and an appropriate code has been identified.l Diabetes – Patients with diabetes are continuing to be detected and coded at rates higher than expected according to current prevalence modelling. Practices are proactively supporting their patients diagnosed with diabetes, with 79 per cent of diagnosed diabetics completing an annual review. RAPHS also co- ordinates a biannual retinal screening programme for all diabetic patients.l Rheumatic Fever - The children’s Rheumatic Fever outreach service continues to deliver prophylaxis in a timely way with 83 per cent of children receiving prophylaxis within five days of their due date. l CV Disease - Practice support to assess patients at risk and involvement in projects, such as the Cardiovascular Outreach Project, have increased the engagement with high need and at risk populations. Over 1,000 people have been offered CVR screening at outreach events since the programme commenced in 2008. A skilled and dedicated team of outreach nurses have greatly contributed to the success of these events.
43
l Influenza – Practices continue to support the national influenza campaign. l Professional Development - The CME/CNE professional development programme has continued to deliver high quality and well utilised educational opportunities to Rotorua’s community of GPs, practice nurses and administration staff. There were over 149 attendees between 1 January and 31 March 2013.l Iatrogenesis Reporting - Near miss reporting is occurring electronically and forms are being sent to RAPHS. Significant code red events are immediately highlighted to all providers. Near miss reports are being collated and summarised biannually. An improved after hours test notification protocol was implemented this quarter, following a near miss event that highlighted issues the laboratory had when contacting primary care with abnormal results after hours. This outcome illustrates the continuous quality improvements that can derive from the reporting of near miss events.l Cornerstone accreditation – Best Practice Assessment Questionnaires – GPs received their surveys in July 2012. All surveys have been returned. Final collation and summaries are being prepared.
Projectsl Special Response Project – Coding – Focus is on encouraging the consistent coding of smoking, CKD, family history, vulnerable children, diabetes, asthma, cancer, osteoarthritis, COPD and CVD. The project was to be completed during the first half of 2013. The benefits of consistent data capture include but are not limited to: l Accurate health target measurement; l Identification of high need areas; l Projecting resource allocation requirements; l Enabling electronic health information sharing. All practices have consented to participating in this project, and audit reports on problem code usage have been prepared for all practices. A Health Information Standardisation Guide has been developed and distributed, and each practice is being supported by the RGPG Technology Team to migrate to the recommended codes.l Chronic Kidney Disease (CKD) – The aim of the project is to promote the best practice management of CKD. A draft CKD Best Practice guideline, including recommended CKD coding has been endorsed by the RAPHS Clinical Leader, Quality. CKD coding guidelines have been incorporated into the Health Information Standardisation Guide. The project coincided with a CKD CME session in September 2012.
Priority for the next 12 monthsDiabetes Care Improvement Packages (DCIP) – a nationwide initiative that will replace Diabetes Annual Reviews, which focuses on outcomes, is currently under development. DCIP will be implemented by 1 July 2013. A focus for 2013/14 will be on ‘bedding-in’ this new care model. Work on improving data quality through the coding standardisation project, supports and enables the measurement of ‘outcomes’.
44
Integration
Newborn enrolment
Aim: To enrol all newborn babies in primary care, Well Child/Tamariki Ora, Community Oral Health Service and the National Immunisation Register within two weeks of birth.
Benefits to patients and familiesFamilies of newborn babies will be helped to access the health care they need by better communication and coordination between providers.
Achievements to dateInitiating the enrolment process while the mother is still in hospital, is a significant service improvement for patients. Completing enrolment in primary care, allows primary care teams who were chosen by the mother to contact families for early well health checks, and timely commencement of childhood immunisations to ensure that every child has the best possible start to life.The forms are collated weekly and distributed to the appropriate provider. At this stage it is a hard copy form which is signed by the mother and copied. We envisage moving towards an electronic enrolment process in the future, which would allow us to track the babies to ensure they receive the best care. The programme began in September 2012.
Background and rationaleIn the Lakes DHB area approximately 1600 babies are born every year and approximately 56% are Maori. The DHB plans and funds a range of child health services for this population across secondary care, population health, primary care and community care. In the past the number of providers has led to fragmentation and confusion for families and providers. Additionally there has been no process for ensuring all children are engaged and accessing the services they are entitled to.Traditionally when a baby is between four and six weeks of age they are referred to primary care and Well Child Tamariki Ora (WCTO) services and at nine months to community oral health. This has relied on the families accessing new services and navigating the system, leading to some of our most vulnerable children not accessing the most basic of health services and falling through the gaps with no one service or provider knowing which children are accessing services. Key to improvement was providing children and their families with a seamless, easy access from birth into all services that they are entitled to. The newborn enrolment will also provide a system to follow up all newborns and thus ensuring vulnerable children will not fall through the gaps.The project has been developed jointly by RAPHS and Lakes DHB without additional funding.
Priorities for the next 12 monthsSuccess in the future will be measured by the percentage of children engaged in primary care, and also by monitoring of those newborns who attend primary care for their six- month old immunisation. The attendance at oral health by 12 months of age will be another useful performance indicator. We need to progress towards an electronic enrolment system. In addition we are working on aligning the process with the maternity booking-in form. All pregnant women are cared for by a lead maternity carer (LMC) who books the women in for delivery early in pregnancy. For total integration the enrolment information needs to be captured on this form (e.g. who the baby’s GP will be, who the chosen WCTO provider is etc). When the electronic system is in place the information will be self populated onto the form for the mother to consent and sign at birth.
45
Workforce
Maori Health – Kia Ora Hauora and Matakokiri Initiatives
Aim: Increase the number of Maori training in health professions
Benefits to patients and familiesBy Maori for Maori is an accepted approach to improving Maori health access and the turoro/whanau experience, Kia Ora Hauora is a national programme, led in the Midland DHBs’ region by Lakes DHB, that intended to recruit 250 Maori into health career pathways by 2012.The Matakokiri initiative is iwi-led by Ngati Whakaue, supported by Lakes DHB. The objective is to get more tamariki/rangatahi interested in science as a school subject. Science is a pre-requiste for most health study pathways.
Achievements to dateThe Kia Ora Hauora project had a target of 250 Midland Maori enrolled in health study, the latest report (Jan 2013) shows 1,153 Midland Maori enrolled, the highest number of any region in New Zealand.The Matakokiri initiative had a target of 40 tamariki/rangatahi, with 65 attending the week-long science camp.
Background and rationaleFor both of these projects the rationale is that to improve Maori health outcomes, we need to increase our Maori health workforce. To increase our Maori health workforce, we need to increase the number of Maori enrolled in health career study. To increase that number, we need to increase the number of Maori doing sciences at secondary school, as science is a pre-requisite.
Priorities for the next 12 monthsKia Ora Hauora is currently awaiting confirmation of a further three years’ funding, from the MOH, to continue to build on the work programme it has put in place so far. This programme has been successful, based on the achievement of over four times the target.For Ngati Whakaue’s Matakokiri initiative, the iwi are exploring employing a teacher/mentor specifically for science and are looking to track the progress of these tamariki/rangatahi through secondary school, linking to iwi education grants and support packages where possible.
46
Workforce
Taleo online recruitment system
Aim: To provide an IT (information technology) solution that will automate and streamline existing recruitment processes without changing the underlying steps of our recruitment process.
Benefits to patients and familiesHaving the right staff with the right qualifications in a timely manner, ensure we can continue to provide high quality health services to our patients, their families and our community.
Achievements to dateTaleo has been up and running at Lakes for about 11 months. We have noticed significant positive changes as a result of this system: l Shorter timeframes for approvals (new vacancies as well as appointments) l Quicker notifications for candidates l Less hard copies, resulting in cost savings l The ability to send bulk email notifications l The ability to share candidates with other system users and match to candidates to specific vacancies l Electronic history of all transactions relating to a particular vacancy l Electronic talent pool l Detailed reporting data
Background and rationaleAs part of the Midland Regional Recruitment Project this system will be shared across the five Midland DHBs. This will ensure a regional approach to recruitment as well as allow cost savings. Taleo will provide an avenue for approving requests to recruit online, as well as managing candidates through their journey. Recruiting managers will have access to the system and be able to view the candidate CVs online. The system will provide additional benefits to the recruitment process enabling development of a talent pool, notification to potential candidates who have registered a profile when suitable vacancies are advertised, and the use job specific pre-screening questions to assist you in your short-listing process.
Priorities for the next 12 months l Implementation of a link between Taleo and HRIS systems. l Implementation of a regional talent pool.
47
Health Target - Better Help for Smokers to Quit
Secondary Care Smoking Health Target
Aim: That 95% of patients seen in secondary care are offered brief advice and support to quit smoking.
Benefits to patients and familiesBecoming smoke free has considerable health benefits for the smoker and especially for their tamariki and mokopuna.
Achievements to dateQuarters one and two of the 2013-14 year Lakes DHB provided 100% of hospitalised smokers advice to quit.
Systems have been put in place including mandatory smokefree training of staff, data collection, communications and providing pharmacological support. Surrounding this has been a commitment by the DHB to work towards a smokefree New Zealand 2025 and provide support and pharmacological support to all staff who smoke and a cessation clinic based in the Ambulatory/ outpatients department.
Background and rationaleThis is a health target supported by evidence that brief interventions are effective in helping people become smoke free. In addition Lakes DHB has a higher proportion of smokers than the national average. Of particular concern is the rates of Maori and Maori women who smoke in the Lakes population. Reducing the number of people smoking has great health benefits not just for the smoker but also their families.
Priorities for the next 12 months l Continue to meet the target. l Put special focus on pregnant women who smoke and work on a system to collect data on pregnant women who are given advice to quit in pregnancy by their LMC.
48
Health Target - Better Help for Smokers to Quit
Primary Care Help for Smokers to Quit
Aim: To provide assistance to patients to help them quit smoking.
Benefits to patients and familiesThe Western Heights Practice community has a high proportion of smoking patients who did not seek assistance to help them quit smoking, but accepted help when it was provided. This very proactive and supportive approach enabled those who had not considered becoming smoke free to succeed in achieving this goal.
Achievements to dateThe Western Heights Smoking Cessation Project opportunistically delivered smoking cessation advice and offered immediate assistance to quit smoking in the form of counselling and medication to those smokers presenting to the practice. Those smokers accepting assistance to quit were then systematically followed up by practice staff by telephone, text messages or face to face contacts. In the course of a year over 500 smokers were seen, about half of these accepted treatment, and of those treated 27% were successful in not smoking for six months. This project demonstrated the demand for funded cessation services and the effectiveness of general practice based treatment in a hard to reach population. The acceptability of general practice-based cessation services to both providers and consumers was confirmed by a qualitative evaluation.
49
Health Targets
Shorter Stays in ED
The target is 95% of patients will be admitted, discharged or transferred from an emergency department within six hours.
How are we doing?
The Shorter Stays in ED Project Team is led by the GM Clinical Services and membership of the governance group includes l The clinical director, head of department, and clinical nurse manager of ED, project manager and service manager Ambulatory Service. l The group reports to the Lakes DHB Executive and the Lakes DHB Clinical Governance meeting. The group has looked at the flows from ED to inpatient wards and identified ways to improve these.Communication and raising awareness has been key in reducing the stay in the emergency department. An awareness campaign within the hospital via large posters raising staff awareness of the role they can play in achieving the health target and staff lanyards with the project slogan – “We can do it in 6! The Rotorua ED redevelopment was opened in November 2012 with ED gaining increased capacity. This supported the introduction of the Fast Track flow for some patients who won’t require admission. The team members have also trialled a new work stream which supports meeting the demand at the busiest period of the day and provides an improved work stream for the management of GP referred patients.
Lakes DHB 6 Hour Target95% Target
Perc
enta
ge
Jan 2012 - March 2012
Q3
89
Apr 2012 - June 2012
Q4
89
July 2012 - Sept 2012
Q1
88
Oct 2012 - Dec 2012
Q2
92
Jan 2013 - March 2013
Q3
94
Apr 2013 - June 2013
Q4
92
95
75
Series 1
50
Improved access to elective surgery
The Improved Access to Elective Surgery Health Target is reported quarterly and measures elective discharges. l The full year target that is in the Lakes DHB Annual Plan is 3607 discharges. These targets exclude dental and cardiology procedures as well as the minor operation procedures that take place in an ambulatory setting, but do include Avastin and minor skin procedures. l The third quarter report shows that the planned target was for 2619 discharges and the actual number of discharges was 3065 so the achievement was 117%. l This is classified as an Achieved result.Approximately 76% of these discharges had their procedure at Lakes hospitals, 16% at Waikato, and 4% are Venturo.
2012/13 Improved Access to Elective SurgeryHealth Target Delivery by Month
AchievedLakes DHB
0
200
400
600
800
1,000
1,200
Quarter 1 Quarter 2 Quarter 3 Quarter 4
Planned Health Target 2012/13 Actual Discharges
0
500
1,000
1,500
2,000
2,500
3,000
3,500
4,000
4,500
YTD Sep12 YTD Dec12 YTD Mar13 Full Year
Cumulative Planned Health Target 2012/13 Cumulative Actual
Lakes DHB ( 78.29 % )
Other ( 3.83 % )Venturo ( 4.60 % )
Waikato DHB ( 13.29 % )
Lakes DHB Other Venturo Waikato DHB
Local vs out of area discharges
FinancialQuarter
PlannedHealthTarget
2012/13Actual
Discharges
Plan toActual
VarianceYTD Plan YTD
Discharges YTD %
Quarter 1 917 1087 170 917 1087 118.5%Quarter 2 872 962 90 1789 2049 114.5%Quarter 3 830 1016 186 2619 3065 117.0%Quarter 4 988 1090 102 3607 4155 115.2%
3607 4155 548 3607 4155 115.2%
Health Target figures are DHB of Domicile and include Publicly funded, Elective admissions, Surgical purchase units, and Avastin and Skin Lesions reported to NMDS
Report to: June 2013 Date Last Refreshed: 12/08/2013
“It is enormously encouraging to see that all the collective efforts by the Surgical
Services team have resulted in improved access to services, reduced waiting times to
elective procedures and meeting the targets set by the Minister of Health.”
Gerrie Snyman, Clinical Director Surgical & Elective Services
51
Two other elective targets required by the Minister of Health are; l By the end of June 2013 patients are offered an appointment for first specialist assessment (FSA) within five months. We are on target to achieving this . l The services are actively working towards all referrals being offered an appointment within five months for routine and three months for semi-urgent, this is allowing greater flexibility for patients. l By end of June 2013 patients given a commitment to treat receive their procedure within five months. We are on target to achieving this . l Over the past 12 months 86% of patients received their procedure at Lakes hospitals within four months of going on the waiting list. (62% within two months).
Priorities for 2013/2014
These include the setting of measureable aims for improvement areas so that we can monitor progress.
Open for better care is the national patient safety campaign coordinated by the Health Quality and Safety Commission. www.open.hqsc.govt.nz
The campaign focus on reducing harm in the areas of: l Falls l Surgery l Health associated infections l Medication
For Lakes DHB our focuis will be on the following areas:Patient Safety l Falls – align with national campaign l Surgery – align with national campaign l Health associated infections – align with national campaign l Medication - align with national campaign
Patient Experience l End of Life care – progress the work programme l Engaging more with Patients – patient focus groups l Partners in Care programme
Clinical Effectiveness l Clinical handover – roll out across services l Improve care transition to community and work with the community groups l Acute admission assessment document - pilot and roll out new integrated document
Integration l Chronic condition pathway development l Reduce the hospital re-admission rates l Regional elective services l Improving access to cancer services
52
www.lakesdhb.govt.nz
53
QUALITY ACCOUNT
1 July 2012 - 30 June 2013
