HOSPITAL ADVISORY COMMITTEE (HAC) MEETING · HOSPITAL ADVISORY COMMITTEE (HAC) MEETING Wednesday 09...

HOSPITAL ADVISORY

COMMITTEE (HAC)

MEETING

Wednesday 09th

April 2014

10.00am

Note:

• Public Excluded Session 10.00am to 11.00am

• Open meeting from 11.00am

A G E N D A

VENUE

Waitemata District Health Board

Boardroom

Level 1, 15 Shea Tce

Takapuna

Waitemata DHB, Hospital Advisory Committee Meeting 09/04/14 i

HOSPITAL ADVISORY COMMITTEE (HAC) MEETING

09th

April 2014

Venue: Waitemata DHB Boardroom, Level 1, 15 Shea Terrace, Takapuna Time: 10.00am

Committee Members

James Le Fevre – Committee Chair

Lester Levy – WDHB Chair

Max Abbott – WDHB Board Member

Pat Booth – WDHB Board Member

Sandra Coney – Deputy Committee Chair

Warren Flaunty – WDHB Board Member

Tony Norman – WDHB Deputy Chair

Morris Pita – WDHB Board Member

Christine Rankin – WDHB Board Member

Allison Roe – WDHB Board Member

Gwen Tepania-Palmer – WDHB Board Member

Hasan Bhally – Co-opted Member

Susanna Galea – Co-opted Member

Andrew Jones – Co-opted Member

WDHB Management

Dale Bramley – Chief Executive Officer

Robert Paine – Chief Financial Officer and Head of Corporate Services

Andrew Brant – Chief Medical Officer

Jocelyn Peach – Director of Nursing & Midwifery

Debbie Holdsworth – Director Funding

Phil Barnes – Director of Allied Health

Sam Bartrum – GM Human Resources

Paul Garbett – Board Secretary

Apologies: Phil Barnes

AGENDA

DISCLOSURE OF INTERESTS

• Does any member have an interest they have not previously disclosed?

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

agenda?

PART I – Items to be considered in public meeting All recommendations / resolutions are subject to approval of the Board.

TIME 10.00a.m (please note agenda item times are estimates only and that the public excluded

session is from 10.00am-11.00am)

1. AGENDA ORDER AND TIMING

10.00am 2. RESOLUTION TO EXCLUDE THE PUBLIC ......................................................................................... 1

3. CONFIRMATION OF MINUTES

11.00am 3.1 Confirmation of Minutes of Hospital Advisory Committee Meeting (26/02/14) ........................... 2

4. ITEMS FOR CONSIDERATION AND RECOMMENDATION TO THE BOARD

5. PROVIDER REPORT

11.05am 5.1 Provider Arm Performance Report ............................................................................................. 12

6. CORPORATE REPORTS

11.50am 6.1 Clinical Leaders’ Report ............................................................................................................... 92

12.00pm 6.2 Human Resources Report ............................................................................................................ 96

7. INFORMATION PAPERS

12.05pm 7.1 Synthetic Cannabinoids.............................................................................................................. 105

12.15pm PRESENTATION: Awhina Prize Winning Presentation ‘Rekeketanga: A Uniquely Diverse Role’

(Dianna McGregor, Maori Nurse Specialist Gerontology, Waitemata DHB). This was the overall

award winner at the Awhina Awards.

Waitemata DHB, Hospital Advisory Committee Meeting 09/04/14 ii

REGISTER OF INTERESTS

Board/Committee

Member

Involvements with other organisations

Last Updated

Lester Levy Chair – Auckland District Health Board

Chairman – Auckland Transport

Deputy Chair – Health Benefits Limited

Independent Chairman – Tonkin & Taylor

Chief Executive – New Zealand Leadership Institute

Professor of Leadership – University of Auckland Business School

Trustee, Well Foundation (ex-officio member)

20/03/14

Max Abbott Pro Vice-Chancellor (North Shore) and Dean – Faculty of Health and

Environmental Sciences, Auckland University of Technology

Patron – Raeburn House

Advisor – Health Workforce New Zealand

Board Member, AUT Millennium Ownership Trust

Chair – Social Services Online Trust

Board member – Rotary National Science and Technology Forum

Trust

19/03/14

Sandra Coney Chair – Waitakere Ranges Local Board, Auckland Council 12/12/13

Pat Booth Consulting Editor – Fairfax Suburban Papers in Auckland 24/06/09

Warren Flaunty Member – Henderson - Massey and Rodney Local Boards, Auckland

Council

Trustee - West Auckland Hospice

Trustee (Vice President) - Waitakere Licensing Trust

Shareholder - EBOS Group

Shareholder – Pharmacy Brands Ltd

Director – Westgate Pharmacy Ltd

Chair – Three Harbours Health Foundation

Director - Trusts Community Foundation Ltd

12/12/13

James Le Fevre Registrar – Auckland City Hospital

Auckland Helicopter Emergency Medical Service Doctor

Member – Australian Society for Emergency Medicine, Hospital

Overcrowding Subcommittee

27/02/13

Anthony Norman –

Deputy Chair

Board Chair - Northland DHB

Director - Health Alliance NZ Ltd

Director - Health Alliance (FPSC) Ltd

Chair - DHB Shared Services Executive Committee

Trustee and Treasurer - Kerikeri International Piano Competition Trust

Partner - Mill Bay Haven, Mangonui (accommodation provider)

Member - representing the interests of 20 DHBs, of the following

committees: Health Sector Forum; Medication Safety Committee and

Health Sector Relationship Committee

23/01/14

Morris Pita Board Member – Auckland District Health Board

Owner/operator – Shea Pita and Associates Limited

Shareholder – Turuki Pharmacy Limited

Wife is member of the Northland District Health Board

13/12/13

Christine Rankin Member - Upper Harbour Local Board, Auckland Council

Director - The Transformational Leadership Company

CEO – Conservative Party

17/05/13

Allison Roe Member – Devonport-Takapuna Local Board, Auckland Council

Member – Board of Kaipara Medical Centre

Chairperson – Matakana Trail Trust

11/02/14

Waitemata DHB, Hospital Advisory Committee Meeting 09/04/14 iii

Board/Committee

Member

Involvements with other organisations

Last Updated

Gwen Tepania-

Palmer

Chairperson- Ngatihine Health Trust, Bay of Islands

Life Member – National Council Maori Nurses

Alumni – Massey University MBA

Director – Manaia Health PHO, Whangarei

Board Member – Auckland District Health Board

Committee Member – Lottery Northland Community Committee

11/03/13

Co-Opted

Members

Hasan Bhally Member – Association of Salaried Medical Specialists (ASMS)

Recipient of funding for research and advice - Pfizer Anti-Infectives

Recipient of funding for research and advice - Cubist Pharmaceuticals

08/05/12

Susanna Galea Member – New Zealand Medical Association

Member – Association of Salaried Medical Specialists (ASMS)

Member – Medical Protection Society

Associate Director – Centre for Addictions Research

31/03/14

Andrew Jones Member – Public Services Association (PSA)

Chair – Physiotherapy New Zealand Ethics Committee

08/05/12

Waitemata DHB Hospital Advisory Committee Meeting 09/04/14 iv

Waitemata District Health Board

Hospital Advisory Committee Member Attendance Schedule 2014

�� Attended the meeting

x Absent

* Attended part of the meeting only

# Absent on Board business

^ Leave of absence

NAME FEB APR MAY JULY AUG SEPT NOV DEC

Dr Lester Levy (Chair) ��

Max Abbott ��

Pat Booth ��

Sandra Coney ��

Warren Flaunty x

James Le Fevre

(Committee Chair) x

Tony Norman (Deputy Chair) ��

Morris Pita ��

Christine Rankin ��

Allison Roe ��

Gwen Tepania – Palmer ��

Co-opted members

Hasan Bhally ��

Susanna Galea ��

Andrew Jones x

Waitemata DHB, Hospital Advisory Committee Meeting 09/04/14

2 RESOLUTION TO EXCLUDE THE PUBLIC

Recommendation:

That, in accordance with the provisions of Schedule 3, Sections 32 and 33, of the NZ Public

Health and Disability Act 2000:

The public now be excluded from the meeting for consideration of the following items, for the

reasons and grounds set out below:

General subject of

items to be considered

Reason for passing this resolution in

relation to each item

Ground(s) under Clause 32 for

passing this resolution

1. Confirmation of

Public Excluded

Minutes – Hospital

Advisory Committee

Meeting of 26/02/14

That the public conduct of the whole or the

relevant part of the proceedings of the

meeting would be likely to result in the

disclosure of information for which good

reason for withholding would exist, under

section 6, 7 or 9 (except section 9 (2) (g) (i))

of the Official Information Act 1982.

[NZPH&D Act 2000

Schedule 3, S.32 (a)]

Confirmation of Minutes

As per resolution(s) to exclude the public

from the open section of the minutes of

the above meeting, in terms of the

NZPH&D Act.

2. Quality Report That the public conduct of the whole or the







[NZPH&D Act 2000


Privacy

The disclosure of information would not

be in the public interest because of the

greater need to protect the privacy of

natural persons, including that of

deceased natural persons.

[Official Information Act 1982

S.9 (2) (a)]

3. HR Update Report That the public conduct of the whole or the







[NZPH&D Act 2000


Privacy



greater need to protect the privacy of




S.9 (2) (a)]

Negotiations



greater need to enable the board to carry

on, without prejudice or disadvantage,

negotiations.


S.9 (2) (j)]

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Waitemata District Health Board, Meeting of the Hospital Advisory Committee 09/02/14

3.1 Confirmation of Minutes of the Hospital Advisory

Committee meeting held on 26th

February 2014

Recommendation:

That the Minutes of the Hospital Advisory Committee meeting held on 26

th February 2014

be approved.

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Minutes of the meeting of the Waitemata District Health Board

Hospital Advisory Committee

Wednesday 26 February 2014

held at Waitemata District Health Board Boardroom, Level 1, 15 Shea Terrace,

Takapuna, commencing at 10.05a.m

PART I – Items considered in public meeting

COMMITTEE MEMBERS PRESENT:

Sandra Coney (Acting Committee Chair)

Lester Levy (Board Chair)

Max Abbott

Pat Booth

Tony Norman

Morris Pita

Christine Rankin

Allison Roe

Gwen Tepania-Palmer

Hasan Bhally (Co-opted member)

Susanna Galea (Co-opted member)

ALSO PRESENT: Dale Bramley (Chief Executive Officer)

Andrew Brant (Chief Medical Officer)

Robert Paine (Chief Financial Officer and Head of Corporate Services)

Jocelyn Peach (Director of Nursing and Midwifery)

Phil Barnes (Director of Allied Health)

Sam Bartrum (Director of Human Resources)

Debbie Eastwood (GM Medicine and Health of Older People Services)

Linda Harun (GM Child, Women and Family Services)

Jenny Parr (Associate Director of Nursing)

Paul Garbett (Board Secretary)

(Staff members who attended for a particular item are named at the

start of the minute for that item.)

PUBLIC AND MEDIA REPRESENTATIVES:

There were no public or media representatives present.

APOLOGIES: Resolution (Moved Sandra Coney/Seconded Gwen Tepania-Palmer)

That the apologies from James Le Fevre, Warren Flaunty and Andrew

Jones be received and accepted.

Carried

WELCOME: The Acting Committee Chair welcomed those present.

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DISCLOSURE OF INTERESTS

There were no additions or amendments to the Interests Register.

With regard to the agenda for this meeting, Lester Levy noted his standing interest in

matters relating to HBL.

1. AGENDA ORDER AND TIMING

Items were taken in the same order as listed in the agenda, with the public excluded

session being held first, from 10.08a.m until 10.57a.m. A section of the Provider Arm

Report (Mental Health and Addiction Services) was delayed and considered later in

the meeting after Item 6.1.

2. RESOLUTION TO EXCLUDE THE PUBLIC (agenda page 1)

Resolution (Moved Sandra Coney/Seconded Gwen Tepania-Palmer)

That, in accordance with the provisions of Schedule 3, Sections 32 and 33, of the NZ

Public Health and Disability Act 2000:

The public now be excluded from the meeting for consideration of the following

items, for the reasons and grounds set out below:

General subject of


Reason for passing this resolution

in relation to each item



1. Confirmation of

Public Excluded

Minutes – Hospital

Advisory Committee

Meeting of 06/11/13

That the public conduct of the whole or

the relevant part of the proceedings of

the meeting would be likely to result in

the disclosure of information for which

good reason for withholding would

exist, under section 6, 7 or 9 (except

section 9 (2) (g) (i)) of the Official

Information Act 1982

[NZPH&D Act 2000, Schedule 3, S.32 a]

Confirmation of Minutes

As per resolution(s) to exclude the

public from the open section of

the minutes of that meeting, in

terms of the NZPH&D Act.

2. Quality Report That the public conduct of the whole or







Information Act 1982.

[NZPH&D Act 2000, Schedule 3, S.32 a]

Privacy

The disclosure of information

would not be in the public

interest because of the greater

need to protect the privacy of




S.9 (2) (a)]

3. Medication Safety

Report

That the public conduct of the whole or








[NZPH&D Act 2000 Schedule 3, S.32 a)]

Commercial Activities




need to enable the Board to carry

out, without prejudice or

disadvantage, commercial

activities.


S.9 (2) (i)]

4 of 107


General subject of


Reason for passing this resolution

in relation to each item



4. HR Update Report That the public conduct of the whole or








[NZPH&D Act 2000 Schedule 3, S.32

(a)]

Privacy




need to protect the privacy of




S.9 (2) (a)]

Negotiations




need to enable the board to carry

on, without prejudice or

disadvantage, negotiations.


S.9 (2) (j)]

Carried

10.08a.m to 10.57a.m – public excluded session

10.57a.m – the Committee resumed in open session.

3. COMMITTEE MINUTES

3.1 Confirmation of the Minutes of the Meeting of the Hospital Advisory Committee

held on 12 December 2013 (agenda pages 2-14)

Resolution (Moved Sandra Coney/Seconded Christine Rankin)

That the minutes of the meeting of the Hospital Advisory Committee held on 12

December 2013 be approved.

Carried

Matters Arising

Disability and Way Finding Project – in answer to a question, Jocelyn Peach

confirmed that the parking spaces for disabled service users next to Ward 11 at

North Shore Hospital are as close to the Ward 11 entrance as they can be and the

closest feasible to the main entrance.

4. ITEMS FOR CONSIDERATION AND RECOMMENDATION TO THE BOARD

There were no decision items.

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5. PROVIDER ARM PERFORMANCE REPORT

5.1 Provider Arm Performance Report – December 2013 (agenda pages 15-96)

Executive Summary/Overview/Scorecard/Human Resources

Robert Paine (Chief Financial Officer and Head of Corporate Services) noted a

correction on page 18 of the agenda. The Provider Arm was $346,000 adverse to

budget at the half year point, not $346,000 positive to budget.

Matters covered in discussion and response to questions included:

• With the DNA results on page 18 of the agenda, it was confirmed that the

‘total’ figures include Maori and Pacific.

• In answer to a question, Cath Cronin advised that they don’t yet have a

estimate of what the cost of DNAs is to the organisation on an annual basis,

however that is being considered.

Medicine and Health of Older Peoples Services

Debbie Eastwood (General Manager, Medicine and Health of Older Peoples Services)

and Dr Jonathan Christiansen (Head of Division Medical) were present for this

section of the report.

Debbie Eastwood commented on the End of Life Care Programme as an area

identified as needing focus.

No questions were raised on this section of the report.

Child, Women and Family Services

Linda Harun (General Manager, Child, Women and Family Services) and Dr Meia

Schmidt-Uili (Clinical Director Child Health) were present for this section of the

report.

Matters highlighted included:

• Child Health Redesign continuing (pages 49-50 of the agenda), moving to a

single point of entry.

• Auckland DHB-Waitemata DHB Women’s Health Collaboration (pages 50-51 of

the agenda). The aim is to make sure that both Boards can deliver the very

best service by working together. Dale Bramley noted that maternity services

at Waitakere Hospital need upgrading and how to address that needs to be

established before other substantive change occurs.

In response to a question, the Committee was advised that the audit of Muriwai

Ward (page 30 of the agenda) is being undertaken by a multi-disciplinary team and

it is of no particular significance that the person leading facilitation of meetings with

families is a speech therapist. The focus of the audit is linking with families and

preparing them for discharge home of family members.

Linda Harun and Meia Schmidt-Uili were thanked by the Acting Committee Chair.

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Surgical and Ambulatory Services and Elective Surgery Centre

Cath Cronin (General Manager, Surgical and Ambulatory Services), John Cullen

(Head of Division Medical and Director ESC) and Mark Watson (Group Manager ESC)

were present for these sections of the report.


• Cath Cronin advised that two major areas of focus are looking at volumes and

increasing utilisation of the ESC, involving planning both for this year and next

year; and making sure that achieving ESPI 1,2 and 5 targets are on track.

• John Cullen advised that over the last few weeks the Elective Surgery Centre

had been achieving the number of procedures that it was contracted to do

and that issue is now sorted, although it will not be feasible to catch up on the

shortfall for the earlier months.

Matters covered in response to questions included:

• John Cullen advised that there had been changes in the way in which patients

are processed, to ensure they do come across to the ESC. The issue of

volumes has been sorted out for the current three operating theatres,

although to get the numbers needed for the fourth will be a challenge.

• Cath Cullen advised that with procurement they are continually working to

get the best price through healthAlliance and HBL. There is quite an advanced

programme with them and some good progress has been made.

Provider Arm Support Services

No issues were raised.

Mental Health and Addiction Services

Helen Wood (General Manager, Mental Health and Addiction Services) and Murray

Patton (Clinical Director Mental Health) were present for this section of the report.


• The high level of acute demand over the previous five months. There are

transition plans that should address that, but the system is under a lot of

pressure. There are short, medium and long term plans (including the high and

complex needs patients plan being considered by the Board later on 26

February). Over all of the Mental Health and Addictions Services there has

been an overwhelming increase in the numbers coming through the doors.

• The four day outage of HCC - Regional Mental Health clinical notes system

(pages 60-61 of the agenda) had highlighted the need for a more urgent

response in such cases from healthAlliance.

The Board Chair advised that he had spent three hours the previous Monday with

mental health staff members in the West. Some of the things that had stood out was

that staff members are very realistic about what is feasible; there is a quite refined

understanding about values; they are very constructive and thoughtful, but having

7 of 107


to deal with a big workload. He had been very impressed and had spoken to the

Chief Executive about a few issues.


• Synthetic cannabinoids – Murray Patton advised that where there are pre-

existing mental conditions, synthetic cannabinoids make these worse. There

are also a lot of examples where people with no history of prior mental health

issues use these substances and become acutely unwell. Helen Wood advised

that she has reinforced the need for staff to report every time that there is an

adverse effect identified from these products. The Acting Committee Chair

requested information on synthetic cannabinoids be reported to the

Committee.

• Murray Patton thanked the Board Chair for his visit to the west on the

previous Monday, as staff members had appreciated the opportunity to talk

with him. A lot of the work they do goes unnoticed and unreported. A lot of

their work is based in the local communities. There may be a need to think

about how to make their work more apparent to the Board in an ongoing way.

• The Acting Committee Chair requested that some visits to hospital facilities be

scheduled for Board members, particularly the new members, as at the start

of the last Board term. These might be relatively short, for example scheduled

before CPHAC meetings.

Provider Arm Performance Report – January 2014

This summary update had been tabled and distributed at the meeting.

The Chief Executive noted that financially the DHB remains on track to achieve a

surplus for 2013/14. He also acknowledged Cath Cronin for leading (with the support

of the other GMs) the work that had seen the major issue with ESPI 1 compliance

addressed and full compliance achieved. This had involved a huge amount of work in

every service and division, and also with the Booking and Scheduling team. The

Committee asked that the Board’s appreciation be included in the acknowledgement

that is taking place of this work.

Resolution (Moved Sandra Coney/Seconded Christine Rankin)

That the Provider Arm Performance report be received.

Carried

6. CORPORATE REPORTS

6.1 Clinical Leaders’ Report (agenda pages 97-101)

Phil Barnes (Director Allied Health) and Dr Jocelyn Peach (Director Nursing and

Midwifery) were present for this item.

Phil Barnes highlighted and/or updated aspects of his report, including:

• Collaboration between laboratory and pharmacy services as described on page 98

of the agenda.

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• Some Allied Health therapists have been using IPads and finding them much more

efficient.

• Development of the Therapy Assistant workforce – Waitemata DHB has the first

cohort of any DHB in New Zealand.

In response to questions, Phil Barnes advised:

• New Zealand is somewhat behind in terms of e-laboratory ordering and e-

radiology ordering. This is close to being resolved here.

• The idea of capturing some value from innovation in terms of copyright etc. is kept

in mind.

Jocelyn Peach highlighted and/or updated aspects of her report including:

• The CNM Leader Development Programme ‘Leading Quality Care’ (pages 109-110

of the agenda) being led by Jenny Parr and her team. Charge Nurse Managers are

really important in the organisation as they set standards, tone and quality, make

sure that things are done efficiently and effectively and have to manage both their

team and the public interface. Sometimes this demanding role leaves them tired or

exhausted and so Part 1 of the programme has been to build resilience for this

group. Those involved were excited with and committed to the programme.

• The Nursing Council of New Zealand audit of Professional Development and

Recognition Programme (page 100 of the agenda). This programme has been going

since the 1980s and over 65% of our nurses have competencies. 560 portfolios

were assessed last year.

• New graduate programme intake – in each of the three DHBs in the Auckland

region, between 70 and 76 new graduates had started the previous week.

Regionally 6.7% were Maori and 13% Pacific. For Waitemata DHB, 4% were Maori

and 6.8% Pacific. This year there had been a lower number of Maori applying. The

enthusiasm new graduates bring is always special and the aim is to try and keep

that going through their first year.

• An emergency planning exercise will run in April based on the hospital being

incapacitated and a regional response being required.

Resolution (Moved Sandra Coney/Seconded Gwen Tepania-Palmer)

That the report be received.

Carried

6.2 Human Resources (agenda pages 102-110)

Sam Bartrum (Director of Human Resources) introduced the report, highlighting:

• The project looking at running hospital services 24/7 – the first part of this is

to look at weekend services and that is getting underway.

• Values implementation is going very well, with a lot of work linking values with

behaviours.

• The scholarship programme – updating the information on page 106 of the

agenda, on 25 February 15 scholarships had been awarded to 15 students, all

Maori.

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• The successful joint bid from the three Auckland Region DHBs for the Pacific

Health Science Academy and Mentoring Programme (detailed on page 106 of

the agenda).


• There had been a great uptake from staff in joining the new staff gymnasium,

with over 700 staff members signing up in the last week. Responsibility for the

gym had now been handed over to Occupational Health and Safety. The Board

Chair suggested that all Board members take the opportunity to look at the

gym.

• With regard to the recent scholarship selection process, there had been

enough applicants to require a quite rigorous selection process. Those

students who had earned the scholarships had prepared and studied and went

through an interview process. There had been a lot of whanau support visible

at the awards on 25 February.

• The Board Chair noted that the same affirmative action approach being taken

with the scholarships is also being taken by Auckland and Canterbury DHBs.

For other students who face financial difficulties there are quite a lot of

scholarships available around the country.

• In answer to a question from the Acting Committee Chair, the Committee was

advised that although the Board’s MOUs are with Ngati Whatua and the

Waipareira Trust, Ngati Whatua does take a leadership and co-ordination role

with other Maori in the District, such as Te Kawarau o Maki. Naida Glavish

could advise members about this. Also the DHB’s Maori workforce is open to

all Maori.

Resolution (Moved Pat Booth/Seconded Tony Norman)


Carried

7. INFORMATION PAPERS

There were no information papers.

The Acting Committee Chair thanked those present.

The meeting concluded at 12.05p.m.

SIGNED AS A CORRECT RECORD OF THE WAITEMATA DISTRICT HEALTH BOARD HOSPITAL

ADVISORY COMMITTEE MEETING OF 26 FEBRUARY 2014

_____________________________________ ACTING COMMITTEE CHAIR

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Actions Arising and Carried Forward from

Meetings of the Hospital Advisory Committee

as at 1st

April 2014

Meeting Agenda

Ref

Topic Person

Responsible

Expected

Report

Back

Comment

HAC

12/12/13

5.1 Provider Arm Report:

- Child poverty – breakdown

of where located in the

Waitemata DHB area to be

provided for Board members.

Tim Jelleyman

Actioned. Sent to

HAC members on

11th

March 2014.

HAC

26/02/14

5.1 Provider Arm Report:

- Synthetic Cannabinoids –

information on this issue to

be reported to HAC

- Visits to hospitals facilities –

to be arranged for Board

members, particularly new

Board members.

Susanna Galea

Peta Molloy

HAC

09/02/14

Separate report

included on agenda.

11 of 107


5.1 Provider Arm Performance Report – February 2014

Recommendation


___________________________________________________________________________ Prepared by: Robert Paine (Chief Financial Officer) and Andrew Brant (Chief Medical Officer)

This report summarises the Provider arm performance for February 2014.

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Provider Arm Performance Report

Table of Contents

Glossary

Executive summary

Scorecard

Health Targets

Financial Performance

Human Resources

Divisional Reports

- Medicine and Health of Older People services

- Child, Women and Family services

- Mental Health and Addiction services

- Surgical and Ambulatory services

- Elective Surgery Centre

- Corporate Services Group

13 of 107


Glossary ACC Accident Compensation Commission

ADU Assessment and Diagnostic Unit

ARDS Auckland Regional Dental Service

BT Business Transformation

CADS Community Alcohol, Drug and Addictions Service

CAMHS Child, Adolescent Mental Health Service

CNM Charge Nurse Manager

CLAB Central Line Associated Bacteraemia

CT Computerised Tomography

CW&F Child, Women and Family service

DNA Did not attend

ESPI Elective Services Performance Indicators

FSA First Specialist Assessment (outpatients)

FTE Full Time Equivalent

ICU Intensive Care Unit

iFOBT Immuno Faecal Occult Blood Test

MHSG Mental Health service group

MoH Ministry of Health

MTD Month To Date

MOSS Medical Officer Special Scale

NOF Neck of Femur

NSH North Shore Hospital

OHBC Oral health business case

ORL Otorhinolaryngology (ear, nose, and throat)

PACU Post-operative Acute Care Unit

PHO Primary Health Organisation

PoC Point of Care

SCBU Special care baby unit

SMO Senior Medical Officer

SSU Sterile Services Unit

TLA Territorial Locality Areas

WIES Weighted Inlier Equivalent Separations

WTH Waitakere Hospital

YTD Year To Date

Information to assist with understanding the scorecard:

For each measure the green bar reflects how well we are doing against the target for the period (ie. July 2013).

The progress green bar is weighted for each measure based on the degree of concern of any short fall in meeting

the target. The analysts within each service have provided an initial estimate of the weighting for each measure

based on prior performance; however this element of the scorecard is still work in progress for some of the

measures. For example, this weighting is noticeable for Elective Volumes where the scale is very sensitive so

that any variance is deemed to be significant. If performance is achieving or better than target, the bar will

display as a solid green line.

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Executive Summary / Overview

Overall assessment


For the month of February, the Provider Arm had a surplus of $2.935m against a budgeted surplus of $2.919m

and is therefore slightly favourable by $16k.

The entire DHB result was also favourable to budget by $67k for the month.

Service Delivery

The health targets for better help for smokers to quit, shorter waits in emergency departments and elective

surgery were all met in December.

The overall Did Not Attend rate (DNA) for first specialist attendances was 11.9% in February, the highest rate

reported since September 2013. Maori and Pacific rates continue to be much higher than those for the total

population, especially for first specialist assessments.

Cath Cronin is the Lead GM for the DNA project for the Provider Arm. The project is tasked with understanding

why the DNA rate for our Maori and Pacific Island patients is disproportionately high in comparison with other

ethnic groups. Key areas of concern have been identified from questionnaire findings, data analysis and

literature review and recommendations are being developed to improve our services to both Pacific Island and

Maori patients and whanau.

The project lead, Lael Meredith is currently working with staff from the Provider Arm, Cultural Support Teams,

Planning and Funding, Business Support and Primary Care to improve reporting on DNAs and develop options,

which can be tested and implemented to improve engagement with Maori and Pacific patients and reduce DNA

rates. Details of patient and health provider questionnaire findings, data analysis and literature review have been

collated and are being socialised with project steering and working groups. Recommendations are being

developed for key areas identified. Initial findings are indicating that we will be in a position to identify areas to

improve our services to both Pacific Island and Maori patients and whanau.

ESPI2 and ESPI5, the MoH indicators for outpatient and inpatient waiting times, were both within the Ministry of

Health buffer range. From March we plan to have all services 100% compliant and will endeavour not to use the

MoH buffer.

15 of 107


Scorecard

16 of 107


Health Targets

Better Help For Smokers To Quit

Shorter Stays in Emergency Departments

17 of 107


18 of 107


Emergency Department Presentations

1,000

1,200

1,400

1,600

1,800

2,000

2,200

2,400

2,600

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52

Pre

sen

tati

on

s

Calendar Weeks

WDHB ED Presentations

Calendar Years from 01 Jan 2008 to 09/03/2014

2008 2009 2010 2011 2012 Mean from Aug 2010 2013 2014

Improved Access to Elective Surgery

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Elective Performance

Zero patients waiting over 5 and over 4 Months

Specialty Compliant Non

Compliant

Non

compliance %

Specialty Comp

liant

Non Compliant Non

complianc

e %

ESPI2 10,529 15 0.18% ESPI2 9424 1120 10.62%

ESPI5 3,670 27 0.73% ESPI5 3407 290 7.84%


Compliant

Non

compliance %

Compliant Non

Compliant

Non

compliance %


Compliant

Non

compliance %

Anaesthesiology 91 0 0.00% 91 0 0.00% Cardiology 201 0 0.00%

Cardiology 1,130 2 0.18% 986 146 12.90% General Surgery 831 2 0.24%

Dermatology 58 0 0.00% 57 1 1.72% Gynaecology 532 1 0.19%

Diabetes 150 0 0.00% 140 10 6.67% Orthopaedic 973 18 1.82%

Endocrinology 247 0 0.00% 238 9 3.64% Otorhinolaryngology 746 5 0.67%

Gastro-Enterology 921 0 0.00% 776 145 15.74% Urology 387 1 0.26%

General Medicine 434 0 0.00% 390 44 10.14% Total 3670 27 0.73%

General Surgery 1,367 1 0.07% 1247 121 8.85%

Gynaecology 895 0 0.00% 813 82 9.16%

Haematology 79 0 0.00% 78 1 1.27%

Infectious Diseases 15 0 0.00% 15 0 0.00% Specialty Compliant Non

Compliant

Non

compliance %

Neurology 17 0 0.00% 17 0 0.00% Cardiology 192 9 4.48%

Oncology 20 0 0.00% 20 0 0.00% General Surgery 800 33 3.96%

Orthopaedic 1,723 11 0.65% 1465 269 15.51% Gynaecology 512 21 3.94%

Otorhinolaryngology 1,308 1 0.08% 1104 205 15.66% Orthopaedic 892 99 9.99%

Paediatric MED 923 0 0.00% 917 6 0.65% Otorhinolaryngology 659 92 12.25%

Renal Medicine 83 0 0.00% 83 0 0.00% Urology 352 36 9.28%

Respiratory Medicine 306 0 0.00% 282 24 7.84% Total 3407 290 7.84%

Rheumatology 212 0 0.00% 210 2 0.94%

Urology 550 0 0.00% 495 55 10.00%

Total 10,529 15 0.18% 9,424 1,120 10.62%

ESPI5 Summary (1% Compliance Buffer) - Compliant 4

months

ESPI Compliance Summary Report - 5 months ESPI Compliance Summary Report - 4 months

ESPI2 Summary (0.4% Compliance Buffer)

ESPI5 Summary (1% Compliance Buffer) - Compliant 5

months5 months 4 months

90% of outpatient referrals acknowledged and processed within 10 days

ESPI 1 Compliance Summary

Specialty Cases Authouris

ed In Time

Frame

ESPI 1

Compliance

Anaesthesiology 95 95 100.00%

Cardiology 516 505 97.87%

Dermatology 57 46 80.70%

Diabetes 235 231 98.30%

Endocrinology 192 181 94.27%

Gastro-Enterology 1033 996 96.42%

General Medicine 269 264 98.14%

General Surgery 615 582 94.63%

Gynaecology 416 404 97.12%

Haematology 157 151 96.18%

Infectious Diseases 26 26 100.00%

Neurology 23 20 86.96%

Oncology 52 52 100.00%

Orthopaedic 685 668 97.52%

Otorhinolaryngology 493 491 99.59%

Paediatric MED 398 393 98.74%

Renal Medicine 104 104 100.00%

Respiratory Medicine 242 242 100.00%

Rheumatology 130 129 99.23%

Urology 256 254 99.22%

Total 5,994 5,834 97.33%

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All Services

21 of 107


COMMENT ON MAJOR VARIANCES

Summary

The provider arm is $656k unfavourable to budget year to date, having reported a surplus of $2,130k against a

budgeted surplus of $2,786k. The year end forecast is a surplus of $1,112k, being $112k favourable to budget.

In the month of February the Provider Arm made a surplus of $2,935k which was $16k favourable to budget.

Revenue

The month’s revenue is $775k favourable to budget, which brings the YTD position to $4.052M favourable. The

main contributors to the monthly variance are $250k from the National Haemophilia Group, Slark Hyperbaric

billings of $88k, $170k of revenue from non-resident patients treated under the ACC contract and interest

earnings ahead of budget by $160k.

The YTD favourable variance consists of an additional $2.0M for the National Haemophilia Management Group

savings initiative, bank interest of $1.5M above budget and a positive variance of $277k from the car parks.

Additional funding has also been received; in Mental Health $260k to provide Adult MH respite in North and

Rodney, $446k in Radiology for the reduction of CT MRI waitlists, $1.25M for beds (short stay and older adults)

and the SLARK Hyperbaric Unit in MedHops. These are offset by a shortfall in non-resident revenue of $643k,

lower surgical services ACC revenue of $346k, and a shortfall of $516k in revenue from repatriation of patients

from Starship, lower than expected revenue in Forensics of $324k and in radiology of $248k.

Full year forecast revenue is $6.032M favourable. This arises from unbudgeted Hyperbaric revenue and ACC

volumes ahead of budget in MedHops $1.726M, additional $3.0M for the National Haemophilia Management

Group savings initiative, car park revenue in excess of budget in Hospital Ops $318k, Corporate revenue ahead

budget principally bank interest $557k. Offsetting this is a shortfall in funding for colposcopy, transfers from

Starship and dental revenue in CWF $1.335M.

Expenditure

Expenditure for the Provider arm was overall unfavourable for the month ($759k) and YTD ($4.709M). Within

this is an under spend in personnel costs for the month ($541k) which has increased the YTD underspend ($546k).

Staff costs year to date variances:

• Medical Personnel ($1.159M unfavourable) –The YTD overspend relates primarily to anaesthetic medical

costs incurred in surgical services in respect to cover in ESC. These costs have been budgeted in outsourced

services. In addition there have been $1.1M of unbudgeted professional membership costs. Offsetting

these overspends is a $1.372M underspend in allowances. In FTE terms the Provider Arm is over budget with

over recruiting of RMOs (17 FTE) and MOSS (6 FTE) being offset by under recruitment of SMOs (18 FTE).

• Nursing Personnel ($386k unfavourable) –In MedHops the favourable nursing spend variable of $216k was

lower than prior months due to recruitment in medical and ATR wards but the difficulty in recruiting to

nursing positions earlier in the year continues to have a favourable effect on the YTD result ($778k). Mental

Health Services has also experienced nursing staff cost underspends ($832k YTD) from positions previously

held vacant in advance of service reviews and better management of acuity in the inpatient units. Other

operating units have reported smaller favourable variances. These favourable variances are offset by

unfavourable variance in centralised nursing savings budgets ($2.633M).

• Allied Health Personnel ($470k favourable) – $470k of this variance arises in the CWF division as both the

Child Health and Regional Dental services delay recruiting into some budgeted positions. Child Health will

not fill roles until they are confirmed as part of their service redesign. Mental Health Services are $652k

favourable YTD due to vacancies in the community teams and annual leave taken in excess of planned.

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Offsetting these favourable variances is a $323k unfavourable variance in S&AS due to unmet savings plans

which are being achieved in other areas of expenditure.

• Support and Admin Personnel ($1.621M favourable) – The bulk of the underspend in Support staff costs

relates to vacancies in orderlies and cleaning staff ($984k) which are covered by the use of outsourced

agency casual staff. 26 FTE of vacancies across Corporate and Facilities Groups (Finance, HR, Quality,

Maintenance, Admin and CIO) have contributed a further $1.259M to the YTD underspend with $649k being

spent in outsourced staff to cover some of the positions. There was also $269k of savings from the ACC levy

reduction in central budgets. Offsetting this is $875k of overspend in MedHops and S&AS due to budgeted

savings being achieved in other areas.

Staff costs year end forecasts:

Forecast staff costs are $1.497M favourable. Substantial underspends in Mental Health Services ($3.061M), due

to positions being held ahead of service reviews, in CWF ($1.349M), due to difficulty in recruiting Child and

Women’s health SMO positions and the holding of dental therapist positions until new graduates become

available. These underspends will offset overspends in S&AS ($1.613M) due to the cost of Anaesthetists

budgeted under POC in ESC and unmet savings initiatives in Provider Support Services.

Non staff costs year to date variances:

Non staff costs were unfavourable by $5.255 YTD. Of this $1.053M related to overspends on outsourced services,

mainly related to the cost of non-medical agency staff ($4.043M) covering vacant positions on wards ($1.104M)

and support areas ($2.7373M finance, cleaners, orderlies, records, transcription and telephone operators).

Offsetting this are underspends on outsourced medical costs ($1.545M) and outsourced clinical services

($1.539M). The outsourced medical underspend arises from lower than planned POC in ESC ($823k) due to lower

volumes, a $1.585M underspend for Anaesthetists costs in ESC (not counted as FTE) which are incurred in staff

costs but budgeted in outsourced costs, offset by $467k of savings lines in SAS which are being achieved

elsewhere and $357k in unbudgeted costs of additional sessions in Mental Health, MedHops and S&AS. The

$1.539M outsourced clinical services underspend relates to a $1.160M underspend against corporate provisions,

$982k favourable variance against central savings initiatives and a $344k underspend in MedHops in the

Hyperbaric, Renal and Older Adults respite services offset by $720k due to Mental Health savings which have

been achieved elsewhere and $401k of unbudgeted CT/MRI outsourcing costs associated with wait list initiatives.

Outsourced services are forecast to be $2.429M overspent for the full year. Clinical services as a whole

contribute $2.107M to the under spend as vacancies are covered through bureau staff in MedHops and MHSG

and some savings planned for this area are achieved elsewhere. Provider Support is also $322k overspent due to

the use of outsourced cleaning and orderly staff .

The YTD $4.532 M unfavourable variances in clinical supplies cost arises in most divisions mainly due to savings of

$2.517M achieved elsewhere, a $1.766M overspend in implants and prosthesis driven by surgical throughput and

cardiac volumes ahead of plan. In addition there was a $1.540M volume-driven overspend in treatment

disposables (principally in Dental, Theatres and Radiology) offset by a $1.189M saving in instruments and

equipment due to the repatriation of the maintenance service from ADHB.

Clinical supplies costs are forecast to overspend by $5.209M in line with the year to date position as a result of

volume driven overspends in treatments consumables. Overspends will be managed through tighter controls

across the provider arm and favourable healthAlliance price negotiations.

The $329k favourable variance in Infrastructure costs relates to $2.499M of unmet savings from professional

services and general operating costs mitigated by other infrastructure underspends such as a $609k underspend

on outsourced cleaning, laundry and orderlies, $252k saving on utilities and maintenance, $762k saving on

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software charges and telecommunications costs and $1.265M interest saving from lower debt balances and

interest rates.

Infrastructure costs are forecast to underspend by $221k for the year. This is in line with the year to date position

and stems from tight control of central administration costs (such as legal expenses, telecoms and training) and

from better than expected interest income.

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Human Resources

Sick Leave

Trends

Current trending mirrors the summer/autumn period last year with sick leave levels starting to rise

February/March. The level is currently still within target.

Highlights/risks

While the levels are still below target the challenge will be to contain sick leave rates as we move into winter.

Planned Actions

Leave management training and continued support from HR Managers/Advisors in their business units to assist

managers pro-actively address instances of high sick leave within DHB policy and practice.

Staff flu vaccination programme commencing in March.

The staff gymnasium is now open and staff are being encouraged to use this facility as part of their wellbeing and

fitness programmes.

Overtime

Trends

Overtime is still above organisational target and increasing again, mirroring increase in sick leave rates over the

same reporting period.

Highlights/risks

Feb 2014 rate is higher than the previous two years and if upwards trend continues this would be a concern in

terms of potential budget impact into the last quarter of the financial year.

Planned Actions

Analysis of ‘red flag’ areas. Continued support from HR Managers/Advisors to managers in implementing

strategies to reduce overtime such as effective leave management and recruitment processes.

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Annual Leave Management (headcount)

Trends

Totals remaining relatively stable with the biggest changes being a decrease in the number of staff with 50-74

days balance but balanced by an increase of approximately 200 staff with up to 24 days.

Highlights/risks

As noted above there has been a decrease in staff with 50-74 days which will be a reflection of active leave

management planning. This needs to continue for both 50-74 days and 75+ days particularly as we move towards

winter where annual leave update is traditionally lower.

Planned Actions

Continued focus in business units of implementing pro-active leave management plans for employees with high

balances with support of HR Managers/Advisors

Staff Retention

Trends

Continued upwards trend in staff resignations within first six months from December 2013 but the level is still less

than previous year.

Highlights/risks

Should this level continue to rise we will need to undertake further analysis. While the current rates are of no

significant concern a continued increase in staff leaving within the first six months will need to responded to .

Planned Actions

Continue to analyse information from exit interviews and work with managers to address any specific concerns or

opportunities for improvement.

Work progressing over the next few months to embed the results of Our Values Your Values will include strategies

to monitor employee engagement. It has been decided to develop these processes within our Values work rather

than implement another stand alone survey. Some of this information has already been gathered through the

listening clinics with staff in the recent In Our Shoes sessions and will continue to develop as we progress.

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Turnover

Trends

Upwards trend from November 2013, but has since declined.

Highlights/risks

While the current rates are of no significant concern, monitoring of staff leaving within the first six months will

continue.

Planned Actions

Continue to analyse information from exit interviews and work with managers to address any specific concerns or

opportunities for improvement.

Work progressing over the next few months to embed the results of Our Values Your Values will include strategies

to monitor employee engagement. It has been decided to develop these processes within our Values work rather

than implement another stand alone survey. Some of this information has already been gathered through the

listening clinics with staff in the recent In Our Shoes sessions and will continue to develop as we progress.

27 of 107


Medicine and Health of Older Peoples Services

Service Overview

This Division is responsible for the provision of emergency care, medical services and sub-specialties (including

cardiology, dermatology, diabetes, endocrinology, gastroenterology, haematology, infectious diseases, renal,

respiratory and rheumatology), and services for older people including assessment, treatment and rehabilitation

(A,T& R), mental health services, and home based support services.

The service is managed by Debbie Eastwood with the Heads of Department Dr Jonathan Christiansen, Medical,

Shirley Ross, Nursing and Tamzin Brott, Allied Health. The Clinical Directors are Dr Hamish Hart for Medicine, Dr

John Scott for Health of Older Adults, Dr Rob Butler for Psychiatry for the Older Adult, Dr Willem Landman for

Emergency Care, Dr Ali Jafer for Gastroenterology, Dr Rick Cutfield for Diabetes/Endocrinology, Dr Tony Scott for

Cardiology, Dr Hasan Bhally for Infection Diseases, Dr Janak De Zoysa for Renal, Dr Megan Cornere for

Respiratory, Dr Ross Henderson for Haematology, Dr Cathy Miller for Palliative, Dr Blair Wood for Dermatology

and Dr Michael Corkill for Rheumatology.

Scorecard

Health Targets Smokefree

The Medicine and Health of Older People Service (MHoP) achieved 95.8% for February against a target of 95%,

with the result for the organisation being 96.3%.

Shorter Stays In Emergency Departments

Shorter stays in ED performance for February was 95.99% for MHoP and 95.7% for the organisation. February has

been challenging for the North Shore ED both in terms of the volume of patients, and the high number of

presentations in short time periods (i.e. greater than 8 patients in 20 minutes which is monitored on a weekly

basis). The increase in ED presentations is demonstrated in the graph earlier in this report with YTD growth in ED

presentations at 4.3% and 6.8% for ADU.

We are working closely with all services to improve their response to ED when patients are referred to their

speciality. We are also monitoring the referral times from ED, i.e. <3 hours and > 3 hours in an effort to ensure

patients are being processed in a timely manner. This can become difficult when a large number of patients

present in a short time period. Bed availability, and therefore flow through ED and ADU, has been facilitated by

opening the Short Stay Ward. Year to date this financial year the utilisation of the short stay ward has been:

Surgical Services 58%, Medicine 38% and Gynaecology 8%. This area is used primarily for patients waiting for

theatre, patients waiting on diagnostic results and patients who are likely to be discharged within 48 hours. The

short stay ward has been open consistently (closed for some days over December only) this financial year.

The information below shows the year on year growth in ED presentations from 2011 along with the impact on

admissions.

% Growth For each Fiscal Year

Hospital Admit To Ward 2011 2012 2013 YTD 2014

YTD 2014 +

Forecast for

Mar-Jun

2012 2013

YTD 2014 +

Forecast for Mar-

Jun

Annual percentage growth

rate from 2011 to 2014WDHB No 70,447 77,673 79,583 54,854 82,281 10% 2% 3% 4%

Yes 27,250 27,255 28,693 20,170 30,255 0% 5% 5% 3%

WDHB % Admitted 28% 26% 26% 27% 27%

North Shore No 37,118 41,165 42,659 29,864 44,796 11% 4% 5% 5%

Yes 20,843 20,406 21,611 15,160 22,740 -2% 6% 5% 2%

North Shore % Admitted 36% 33% 34% 34% 34%

Waitakere No 33,329 36,508 36,924 24,990 37,485 10% 1% 2% 3%

Yes 6,407 6,849 7,082 5,010 7,515 7% 3% 6% 4%

Waitakere % Admitted 16% 16% 16% 17% 17%

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AT&R Wards and Length of Stay

The average length of stay (LOS) for the AT&R wards in February was 22.8 days against a target of 15.50 days.

There are a number of contributing factors to this long Length of Stay. The wards were at times during the

month closed to admissions on the advice of Infection Control and this was coupled with the fewest number of

discharges over the last 12 months (112 against an average of 148 per month). A significant factor was the

discharge of a cluster of complex patients that had much higher than average stays. The ALOS for these five

patients was 74.6 days. There are currently four patients with stays over 30 days awaiting Protection of Personal

and Property Rights (PPP&R) decisions. We are monitoring this delay currently.

Elective WIES & Discharges for Cardiology

WIES for elective cardiology is below contract for the month, however the number of discharges are 125.3%

ahead of target in February. We are planning to run additional elective lists in March and April to ensure we meet

both patient demand and our elective contract.

Complaints The number of complaints received in February was 33 for the month with a turnaround time of 19 days against a

target of 14. We also received 9 requests/inquiries/suggestions.

Other Key Measures Assessment & Diagnostic Unit (ADU) – time to be seen from triage (Medicine) % compliance to 60 minutes

Our result was 50% in February, a slight reduction from the previous two months. We are continuing to work on

understanding the root cause of the delays and as part of this we are reviewing the data related to the time when

the delays occur. The medical teams are also being mobilised to support admitting in ED/ADU when there are

surges in volumes as we have experienced on a number of occasions during February.

Acute readmission rate within 28 days

The analysis of the readmissions audit has been delayed due to the junior doctor’s exams. We are aiming to have

the analysis of the audit completed by the end of March. Whilst we will then need to review the results more

thoroughly, in the interim, one of the key features we have identified as an issue is the need to improve the

information going into Electronic Discharge Summary (EDS) information. The plan for the patient post discharge is

a critical component of the EDS which needs to be completed effectively. The Clinical Director Geriatrics and the

Chief Resident are working on developing EDS examples for junior medical staff to be used as training guides.

Quality

FAST quality improvement project - Managing pain on the medical wards

Wards 3 and 6 have been identified as the pilot wards for this initiative. Data has been collected through patient

and staff surveys and a medication chart audit. Preliminary results show that patients with pain receive analgesia

however they are not having their pain reassessed after administration. The steering group met on the 13th March

to formulate an education plan for improvement and initial findings will be ready for presentation to Clinical

Governance on 23rd March. The plan is to commence education and improvements from 7th April.

HQSC Markers

Falls

Fall audits across all wards in MHoP continue to indicate a steady improvement in the completion of a risk

assessment along with care planning within 8 hours of admission. We are focussing on implementing a package of

care for medium and high risk patients rather than focussing on individual falls prevention strategies. An for

example of this might be 15 minute checks being done in conjunction with a floor line bed and personal falls

alarm.

Hand Hygiene

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Gold auditor training is well underway and a further six nurses from our division are undertaking this opportunity

on 19 March. Once they have completed the training they will immediately be involved in hand hygiene audits,

along with being a resource in the ward and providing interactive education for the nurses on their wards. By

March every medical ward will have at least one member of staff trained as a gold auditor.

Friends & Family

The Friends and Family test in MHoP is progressing well with most of the wards now able to collect feedback daily

as they each have their own tablet. The Charge Nurse Managers are leading this project with Ward 2 currently

achieving the highest number of responses at 80 and ward 10 with 76.

Staff are beginning to understand the data and the value in collecting as many responses as possible to improve

the validity and therefore the value of the feedback from patients and their families.

Total responses collected for MHOP for February are 226.

� 193 inpatient responses (wards)

� 33 from ED

Overall MHOP has a net promoter score of 53%. This is made up of 71.8% promoter, 24.2% neutral and 4%

detractor. The scores are calculated using the underlying net promoter score methodology by analyzing

responses and categorizing them into promoters (would recommend), detractors (would not recommend) and

neutral (passive) responses. The proportion of detractors is then subtracted from the proportion of promoters to

provide an overall ‘net promoter’ score.

Human Resources Thirty three new graduate nurses, totalling 21.6 FTE, joined the MHoP service in February. These nurses are filling

budgeted vacancies across all the wards, Emergency Department and the Assessment & Diagnostic Unit.

The HOD Nursing is leading an education project in partnership with senior nurses from the AT&R wards to up

skill Ward 11 (isolation/infection control ward) nurses to be specifically focussed on the needs of the older adult

patient. We have identified over the past few months that a significant proportion of the patients who are on this

ward are >75 years of age and therefore require care that is appropriate for both their presenting medical

problem, but also their age related requirements.

We are currently advertising for a part time Dermatologist. This will enable us to provide a more appropriate level

of access for community patients via the outpatient service, along with improving the support to the inpatient

services.

The clinical nurse specialist review is progressing, with work groups now being set up to work on areas such as:

generic job description for speciality nurse and clinical nurse specialist, orientation, job planning process and

establishing key performance indicators.

Service Delivery Cardiology achieved 100% compliance with the MoH target of 85% of elective patients receiving their coronary

angiogram within 90 days.

Colonoscopy service delivery – as noted on the scorecard we achieved 55% compliance for the urgent

colonoscopies completed within 14 days. We have been focussing on our non-urgent gastroscopy waiting list

over the last 2 months.

Cardiology is meeting a compliance requirement of 85%, total number is 134 as at 24th February 2014. 100%

compliance for ESPI 5 but local target not achieved. Acceptable wait list is 100 with target 76. This is being

addressed as part of the NSH CVU initiative to increase throughput and session availability and results are not

30 of 107


likely to be evidenced until financial calendar Q3 to 4 2014, depending on the availability of additional PCI

operator resource.

ESPI 1, ESPI 2 & ESPI 5

All specialties continue to be 100% compliant with the 5 month target (ESPI 2 & ESPI 5). There remains a

challenge for cardiology and gastroenterology in terms of ESPI2 compliance. Plans are underway in all services to

achieve 4 months wait times for ESPI2 by June 2014 (target date of October 2014 for Cardiology and

Gastroenterology). The recruitment of an additional Dermatologist will support this small service to sustain their

waiting list at 4 months as will the return of a Respiratory Physician from maternity leave.

The booking and scheduling function undertaken in the Patient Service Centre - Medicine continues to be

reviewed and a restructure of the current functions will be undertaken. This work will be supported by the Quality

team. The specific actions in February are:

• Referrals processes have been reengineered and embedded. • Capacity and demand work for the Patient Service Centre- Medicine staff has been completed. This work

will inform the restructure of this area. • Interviews for a Team Leader of this area are underway, however it is unlikely we will have a successful

appointment.

31 of 107


Scorecard

32 of 107


STRATEGIC INITIATIVES

Deliverable /Action On Target

Increase monitoring and review of waiting times by ethnicity for echocardiograms and

adopt new ways of working that will improve the use of current capacity and reduce

waiting times ��

Direct access for general practitioners to specialist nurse and /or doctor advice in renal,

diabetes, gerontology, dementia and cardiology – confirm current practice and

establish baseline Q1, identify any enablers or process changes required (e.g. processes

to ensure any advice provided is captured in clinical notes) Q2, implement changes

required Q3, direct access in place for identified specialties Q4

��

The Diabetes Centre will explore the option to extend the Mind the GAP (Glucose

Awareness Project) programme once the results of the pilot are known ��

Inpatient hospital services (31 services) will have a trained and resourced smokefree

lead to provide training and support to clinical staff. These leads will be supported and

resourced by the Waitemata DHB Smokefree Team with peer support and monthly

updates

��

Refresh the ABC activity recording form (ATM – Ask, Triage, Manage) in use at

Waitemata DHB ��

Having completed a comprehensive review of the current General Medicine model of

care, redesign the model of care and staffing for General Medicine inpatient services by

September 2013 x

Implement the new model of care by February 2014 x

Continue the development and implementation of clinical pathways which will ensure

standardisation and equity of care for patients in both ED & ADU – 5 pathways to be

reviewed and/or developed by June 2014 ��

Develop a workforce strategy plan for the ED by July 2013 with sign off and initial

implementation by December 2013 x

Implement a semi acute respiratory clinic by July 2013 for winter demand and evaluate

by December 2013 x

Provide LTC workforce education courses to primary health care practitioners –

ongoing ��

Implementation of an staff on-line training tool for thrombolysis staff ��

Use the findings of the Integrated Transition of Care Project to inform development by

October 2013 of a suite of interventions to improve the discharge management

process. Commence piloting the suite of interventions by January 2014. Use participant

feedback for iterative development and re-piloting to achieve a sustainable suite of

interventions by April 2014. Pilot evaluated to determine suitability for rollout across a

range of inpatient services by 30 June 2014

��

Implement the Ministry of Health Elder Abuse Guidelines ��

Deliver secondary preventative care for fragility sufferers (through identification,

investigation and intervention) to prevent hip fractures. This will be supported by the

Minimum data set (MDS) for hip fractures. (Service Level Agreement in progress) ��

Finalise and report the findings of clinical quality audit of Māori referrals for

angiography and angioplasty by September 2013, and develop a business case to

support implementation of recommendations as appropriate ��

Review older people services and clinical pathways ��

Ongoing provider arm services reviews ��

* include a � or a �

33 of 107


Key achievements for month

• The District Nursing project has been shared with NZNO and will be launched with staff in

early March. We are now advertising for an enrolled nurse to join the Rodney team, which

is the pilot site for the new model of care. Meetings are also being arranged with our

internal nursing development team and Unitec in relationship to clinical placements for EN

students and new grad programme.

• The nine month cognitive Impairment pathway pilot commenced as planned on 4th

November 2013 and will run until 31st July 14. By the 31st March 14 the 12 GPs (6 GPs and

their Practice Nurses per ProCare and Waitemata PHOs) will each case find three 65+ year

old patients with previously undiagnosed dementia and 2 with previously undiagnosed

cognitive impairment and with their / their carer’s consent trial the pathway. Two meetings

have been held with clinical directors and key others to progress moving forwards with

memory clinic.

• The Febrile Neutropaenia pathway which was developed by one of our Registrars and our

Acute Care Physician with input from the Haematologists and the Infectious Disease

physicians has now being completed and is now up on General Medicine site.

• The Diabetes Centre will explore the option to extend the Mind the GAP (Glucose Awareness

Project) programme once the results of the pilot are known. The first year of the diabetes

audit provided an excellent picture of our admitted diabetic population. It also identified

opportunities for improvement. Further refinement of the audit process will ensure that the

state of diabetic care continues to improve. The audit also identified a need for

downloadable data from POCT blood glucose monitors. Nine new monitors were ordered in

January and a further six were provided free of charge for a three month period by the

suppliers. Staff training commenced in January for the first three services to trial the

monitors.

• Deliver secondary preventative care for fragility sufferers. A 0.5FTE CNS is currently

delivering a wrap-around service of assessment, treatment, education, and follow for up to

300 outpatients per year. She is supported by a consultant Endocrinologist. Patients are

identified from both the acute fracture clinic based in orthopaedic outpatients at North

Shore Hospital or referred from the ED with relatively straight forward injuries, i.e. they do

not require surgery. The work to date suggests that at least 300 patients at risk of fragility

present for an outpatient appointment each year. Of this group, we estimate that up to two

thirds will not be on appropriate osteoporosis prevention medication. This is our target

population. To enhance our DHB funded service, ACC want to discuss the possibility of a

funding partnership to increase the personnel resources for up to three years to further this

work stream.

Areas off track for month and remedial plans

• ED workforce strategy – the development of the best care bundles in the ED are continuing

to be developed, rolled out and evaluated. Changes to the medical workforce are on hold at

this stage.

• General Medicine roster – as noted in previous reports we are not progressing home

wards/general medicine roster. However we are working with the general medicine teams

to achieve a higher level of home warding at Waitakere Hospital.

• Respiratory semi acute clinic – this initiative has been put on hold as further discussion

between Respiratory and General Medicine has identified this is not a priority as there is

fast track access to a respiratory physician via the outpatient service.

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KEY ISSUES/INITIATIVES IDENTIFIED IN COMING MONTHS

• Telerehab Project –Funding for the tablets for this project has now been agreed and we are

waiting on a final quote before moving ahead and purchasing them. The professional and

clinical Leader for speech language therapy has picked up the lead for this project post the

allied health review. There is currently a focus on finalising the training, identifying the

project outcome measurements and setting training dates post the delivery of the

hardware.

• Ward 6 continues to be fully utilised to its full level of 35 beds, this is primarily to support

surgical patients (elective and acute). This has meant that the projected reduction in

medical bed demand and subsequent financial savings has been compromised. We have had

to ask staff to extend shifts, work overtime and on a number of occasions employ external

bureau to ensure safe nurse to patient ratios are maintained.

• The Regional RMO position request process is underway across the DHB; this work is being

coordinated by the Medical HoD, MHoP on behalf of the organisation.

• User groups have been set up to work on the detailed design for the Podium.

• A project manager has now started working on the business case for additional medical

beds.

• A post implementation review of the Additional Endoscopy Room business case will

commence in late March.

• Commissioning work is progressing to plan for the new community dialysis unit in Apollo

Drive. This unit will open in May 2014.

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Financial Results

COMMENT ON MAJOR FINANCIAL VARIANCES

The overall result for Medicine & Health of Older People was unfavourable by $565k for the month and year to

date $78k unfavourable.

Revenue

Revenue for the February is $41k favourable ($1,283k YTD favourable). ACC revenue in AT&R is $4k unfavourable

for the month; however it is $420k favourable YTD due to higher than budgeted bed day usage for ACC patients

this financial year. AT&R billings to ACC were lower during February as a result of high bed demand within North

Shore hospital which flowed into AT&R reducing beds available for ACC funded patients. There was a shortfall in

the community nursing ACC of $27k ($220k YTD) which is due to lower acuity work being performed by other

organisations contracted directly with ACC. The Slark Hyperbaric also contributed $101k for the month ($562k

YTD) in unbudgeted revenue which fully offset the costs related to this service; this includes $90k YTD revenue

from ACC funded treatments. Cardiology revenue is $214k unfavourable for the month (YTD $231k unfavourable)

due mainly to lower than contracted elective volumes due to leave over the holiday period. Research revenue is

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$5k unfavourable for the month ($22k YTD) however this is fully offset by favourable variances in costs. Additional

funding of $419k YTD has been received fully reimbursing the operating cost of Short Stay Ward YTD and

additional beds in Ward 6 to the end of December. However the Short Stay Ward has remained open for much of

January and February 2014.

Expenditure

Personnel costs overall are $543k unfavourable for February and $85k favourable YTD. Medical staff costs are

$207k unfavourable year to date and this is mainly due to unmet budgeted savings for the Emergency

Department workforce initiative which is now on hold. Unbudgeted medical costs for the Slark Hyperbaric Unit of

$210k YTD are also contributing to the unfavourable variance, however they are offset by revenue. RMO costs are

$449k favourable YTD primarily due to the actual paid allowances being lower than budgeted year to date. RMO

allowances are not being paid to the same extent as previous years due to the increasing number of doctors

available to fill rosters eliminating payment for additional hours, these are being reviewed as part of the forecast

and budget 14/15 build. Nursing staff costs are under spent by $778k year to date, with the main contributor

being vacancies primarily within the wards; this is at both North Shore and Waitakere Hospitals. Nursing staff are

recruited to budget now with only normal level of vacancies reflected in the service.

Contracted FTE for nursing in the division was 928 FTE at the end of June against a budget for 2013/14 financial

year of 1016 FTE (excluding bureau and unplanned leave FTE) therefore we started the year with approximately

88 FTE vacancies or 8.5% of total nursing FTE. Recruitment during the first eight months has increased contract

FTE by 63 to 991, reducing the vacancies to 2.5% of total nursing FTE. The opening of the Short Stay Ward to meet

bed demand has contributed $387k of additional nursing cost which has been fully reimbursed by revenue up

until December. Approximately 4.9% of our nursing spend over the first six months has been a combination of

internal and external bureau, this has been to cover a combination of vacancies and sick leave. Bureau usage to

date remains constant as high occupancy since the Christmas period led to use of temporary resources to top up

the reduced beds/FTE planned for summer.

FTE Staffing levels are below the agreed budget FTE for the division this month with contracted FTE 1686.52

against the budget of 1727.14. Vacancies are the main contributor to this. There has been a net increase of 10.6

contracted FTE across the division in January and February, mainly due to the latest intake of Graduate Nurses.

Other Expenditure

Outsourced Services are $125k unfavourable for the month and $434k unfavourable YTD. External nursing bureau

costs are $820k over budget YTD; however this is offset by the favourable variance in nursing personnel costs.

There were favourable variances for both medical fee for service and clinical services.

Clinical Supplies are unfavourable to budget $556k YTD. PCT drugs are under spent by $22k YTD (despite $173k

relating to under accrued costs from the 2012/13 financial year). Overall PCT costs now include use of these drugs

in Haematology and Rheumatology. Client related costs are over budget by $231k YTD. This is comprised of on-

going costs $85k of ADHB home haemodialysis support (which continues to incur cost due to the delay in the

build of the Apollo Drive Dialysis Unit which is part of the Renal Phase 2 business case) and Mental Health for

Older Adults Respite care over budget by $181k. Implantable Cardiac Defibrillators (ICDs) are over spent by $492k

YTD due to higher than budgeted volumes. This is under review, however all procedures have been audited and

are appropriate within regional guidelines. Further work analysing the volumes is underway. Other areas of over

spend include protective clothing, dressings, monitoring equipment and catheters. These costs will be closely

monitored over the next quarter to ensure any agreed price reductions are realised and where there is volume or

price increases we will seek to mitigated these over spends.

Infrastructure and non-clinical costs are unfavourable by $455k YTD with the most significant overspends coming

from budgeted revenue which has not yet been received, cleaning costs, printing, stationery and postage costs

and one off consulting costs from PwC relating to work in the division on identifying savings opportunities.

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Full Year Forecast

A high level forecast has been prepared for the service based on the January result predicting an over spend of

$1,216k against the budget.

Assumptions include the impact of savings plans, back pay estimates for Cardiology and Older Adults SMO’s,

outsourcing of colonoscopy and gastroscopy and achievement of elective volumes.

Areas of risk are continued high bed demand impacting on nursing and external bureau cost, receipt of additional

$250k funding budgeted but not yet received, extent of available funding from Ministry of Health to offset costs.

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Child, Women and Family Services

Service Overview

This Division is responsible for the provision of maternity, obstetrics, gynaecology and paediatric medicine

services for our community and the Auckland Regional Dental Service (ARDS) for metro-Auckland. Services are

provided within our hospitals, e.g. births and gynaecology surgery, and within our community, e.g. community

midwifery and mobile/transportable dental clinics. The division is managed by Linda Harun with Dr Tim Jelleyman

HOD Medical CWF, Emma Farmer HOD Midwifery; Marianne Cameron HOD Nursing, Ronelle Baker Allied Health

Lead, Dr Sathananthan Kanagaratnam Clinical Director ARDS, Dr Sue Belgrave Clinical Director Obstetrics, Dr Peter

van de Weijer Clinical Director Gynaecology and Dr Meia Schmidt-Uili Clinical Director Child Health. SCORECARD

Health Targets The service continued to deliver better than target on the better help for smokers to quit at 96%.

Elective volumes (gynaecology) are 104% of target overall and the volume delivered in ESC has increased over the

last few months to reach 99% of target YTD.

The service achieved 98% compliance with the 6 hour target in ED. Both Women’s and Children’s services

continue to review all breaches and are working with the ED to improve results.

The gynaecology breaches related largely to a shortage of beds to admit patients in a timely manner.

During February there were 881 children under 15-years who presented to the Waitakere Emergency

Department. During the month there were 18 breaches (paediatric) of the ED 6-hour target (98% compliance).

Each breach continues to be reviewed. These reviews demonstrated there were a number of contributing factors

that led to the breaches. These included:

• Patient acuity, where children required stabilisation in resuscitation prior to transfer to the ward

• Children who were following clinical pathways who required longer than 6-hours in the emergency

department before being discharged home

• Medical staff responding to high volumes of children through the department.

Quality The complaint turnaround time for the service was on target of 14 days. The Friends and Family Test is being trialled in maternity at North Shore and shows a high rate of promoter scores

on a relatively small sample size.

Human Resources The sick leave rate remains above target. The service has several staff on long term sick leave which are being

reviewed with the assistance of Well NZ.

Annual leave balances remain an issue for SMOs. Women’s Health has employed two new SMOs which will

enable existing staff to take their annual leave and should result in overall reduction of high leave balances.

Service Delivery Oral Health Arrears Target

Total arrears have continued to improve reaching overall regional rates of 6.7% and 6.1% for Maori. This has

resulted in volumes of treatments being 23% above the previous year.

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Theatre utilisation

Theatre utilisation remains lower than target largely due to late cancellations. The Women’s Health Service

continues to work with individual SMOs who do not meet the target in order to improve the theatre utilisation.

All theatre lists are reviewed two weeks from operating date to ensure they are fully booked.

Breastfeeding on discharge

Exclusive breastfeeding on discharge remains above target at 78%. This reflects well on the commitment of all

staff to maintain the BFHI status.

Births

Year to date births are slightly above target for the year to date.

Elective Caesarean Sections

The Women’s Health Service has commenced a normal birth project which specifically has the aim of promoting

normal birth. This project is being led by the Maternity Quality and Safety Midwife Co-ordinator. Along with this

project the service audits the Caesarean Section rate and reviews the clinical indications for Elective Caesarean

Sections.

Average length of stay

Length of stay in maternity and paediatrics is slightly below target for the month of February.

ESPI compliance

Both gynaecology and paediatrics are ESPI 2 compliant. The ESPI 2 target moving to 4 months raises some issues

for the Women’s Health Service in relation to the availability of additional clinic rooms and nursing staff. The

service is working closely with both outpatient CNM’s to ensure any available clinic room is booked in advance for

a gynaecology compliance clinic.

Gynaecology is ESPI 5 compliant.

Both Child and Women’s Health services are better than target in achieving ESPI 1 compliance, reaching 95%. The

services both have centralised triaging processes that enable close monitoring of processes. Child Health Services

is now booking and scheduling all paediatric clinics (this responsibility previously sat with Elective Services). The

paediatric booking clerks have been fully oriented into the service and the transfer of responsibility has resulted

in a reduction of clinic booking errors and improved wait list management.

Contracts WIES volumes

Gynaecology Elective WIES volumes remain slightly above target for the year and this is expected to continue

until June. The total WIES delivered in ESC is now close to target and this will be maintained. Gynaecology is

delivering increased total elective volumes to improve the overall elective volumes for the organisation.

Acute gynaecology volumes are close to target.

Maternity WIES volumes are higher than target reflecting the increased complexity of cases now that the DHB is

delivering the Gestational Diabetes service locally. Overall birth numbers are not higher but the numbers of

women requiring complex care has increased.

Paediatrics WIES volumes are now trending towards target. The volumes are always higher in winter and the

summer reduction in volume brings the overall volume down towards the annual target. Currently the service has

delivered 114% of target.

Neonatal WIES is 3% below WIES target reflecting a slight reduction in activity for this period.

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Transfers from Starship Hospital and Out of Area Admissions

There has been a decrease in transfers from Starship ED to Rangatira ward while the number of out of area

admissions has remained static. Discussions are continuing with Starship to streamline these processes and

reduce double handling whenever possible.

Non case weighted discharges

Child health services remain below target in FSA volumes. Paediatrics typically provide more of this volume in

summer and the total year to date volume will continue to improve in the next two months. In addition, there

may potentially be two factors that are influencing FSA volumes: 1) the centralisation of triage across both sites

leading to greater consistency in acceptance (or not) of referrals for assessment; and 2) an increase in virtual

FSAs.

FUP volumes are higher than target due largely to gynaecology volumes. These are being investigated to ensure

accuracy of data. All SMOs planned appointments are being reviewed to determine if a woman needs a FUP

appointment or can be discharged back to her GP.

Child Rehabilitation Activity

Rehabilitation Activity – Total Bed Days (In and Out of Area)

Overall MOH rehabilitation bed days utilised has seen a reduction over the past month. This is due to very low ‘in

area’ bed day utilisation this month (n=1). Decreased overall bed utilisation is also a result of the introduction of

strategies to manage the high volume (beyond contracted levels) of ‘out of area’ bed days. This includes the

delay of planned rehabilitation for some children.

Rehabilitation Referrals

The referrals from outside of the Auckland region have continued to be above target with referrals from Taranaki

and Waikato being the highest users of the service. The referrals from within the Auckland region significantly

reduced this month.

Rehabilitation Activity – ACC Bed Days

ACC volume has shown a spike in referrals resulting in a year to date delivery of 5% above the target.

The ACC contract is a fee for service and the DHB only receives revenue for referrals accepted and services

delivered.

Gateway Assessment Programme Referrals

There has been an increase in the number of referrals received to the Gateway Assessment programme this

month, but the monthly referral rate continues to be much lower than the anticipated volume of 32 per month.

A meeting has been scheduled with the CYF operations manager in late March to highlight concerns about the

low referral rate and identify strategies to improve this.

Assessments Completed

There were 22 completed Gateway assessments this month. This is a significant increase from previous months.

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Children Waiting Beyond Contracted Wait Times

At the end of February there are 42 children who have a completed referral waiting for a Gateway assessment.

This has been reduced each week with the number at 17th March being 26. To date, there are 21 Gateway

assessments scheduled during March.

Gateway referrals

Week

commencing No. of active

referrals Children waiting

beyond

contracted time

frame

Children waiting

beyond

contracted time

frame with

complete referrals

Children waiting

beyond

contracted time

frame with

scheduled appts

17th Feb 114 85 48 16

24th Feb 102 80 46 26

3rd Mar 96 84 42 21

10th Mar 84 75 37 16

17th Mar 70 60 26 14

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Scorecard

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Strategic Initiatives

Deliverable /Action On

Target

Implement Child Emergency Departments and Paediatric Wards immunisation

processes improvement plan

�

Ensure all cases of acute rheumatic fever are notified to the Medical Officer of Health

within 7 days of confirmed diagnosis by June 2014

�

Continue to deliver the hospital-based Family Violence prevention and intervention

programme. For 2013/14, this will include training for mental health social workers,

Auckland Regional Dental Service and on-going DHB generic training via Learning and

Development

�

Work with maternal mental health to implement universal screening for mental health

conditions in pregnancy

�

Progress training of DHB professionals to recognise signs of maltreatment in the

following key services: Child Health, Maternity, Alcohol and Other Drugs, Mental Health,

Sexual Health and Emergency Departments

�

Sign the CYF Schedule 2 (under the Memorandum of Understanding with Child, Youth

and Family Services, Police and DHBs for interagency collaboration for child protection),

which relates to Child, Youth and Family Services funded liaison social worker positions

in all DHBs

�

Policies and reporting systems in place to recognise and report child abuse and neglect �

High level accountability in place for clinicians to routinely screen for family violence as

part of assessing the well-being and safety of children and families

�

Develop and implement a policy to support maternal/perinatal mental health services

screening of pregnant and postpartum women who access provider arm services for

antenatal and post natal care

�

Publication of Annual Maternity and Clinical Reports for 2012 is published in August

2013 and for 2013 data, in August 2014

�

Develop a system for identifying whether children presenting to Child Health Services

are engaged with early childhood education and routinely provide information to

families/whānau on the benefits of early childhood education

�



� The immunisation processes improvement plan has been fully implemented in Rangatira ward.

� Public health nurses and social workers are opportunistically promoting early childhood

education attendance with families where there are pre-schoolers. Parents are also made aware

of the Before School Check and the process for arranging an appointment. Specifically, staff are

talking with parents about school readiness and provide information on how they can apply for

20-hours free early childhood education. The Waitakere Child & Family team continue to be

involved in the Success for Little People Initiative. The long term goal of this initiative is to

ensure that all 5-year olds living in West Auckland are enrolled in school, ready for school and

are attending every day with the support of their families

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OTHER HIGHLIGHTS Before School Check (Vision & Hearing Component)

There has been an increase in the number of screens completed this month, with the service now at

6% below the expected target.

The February 2014 report from the Ministry of Health indicates that Waitemata DHB has almost

reached the year to date target for Before School Checks and is the highest performing DHB in the

Northern region.

Rheumatic Fever Programme

School Based Swabbing Programme

The swabbing programme is operational in all five high risk schools within the Waitemata district. Of

note, 100% of children in all five schools have consented to participate in the programme. 491

swabs were taken this month and 16% (n=79) of children swabbed had a GAS+ result.

During February there has been a particular focus on updating school rolls. Also, each of the

thirteen schools in the Waitemata district that have been identified as moderate risk have been

allocated a public health nurse. Each school will receive an information pack on rheumatic fever and

advice on other available resources. The schools will be offered education sessions for staff and the

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broader community. These will be delivered after a short survey is completed, which ensures that

the sessions are tailored to each school community’s needs. It is anticipated that the education

sessions will be undertaken in partnership with NGOs, Maori and Pacific health providers with the

local community. Schools will also be shown the National Heart Foundation curriculum tool and

encouraged to use it. The plan is to utilise any up and coming school community events to deliver

education and promotion to these communities.

Auckland Wide Health Housing Initiative (AWHI)

A working group (across community and inpatient services) has been established to develop

pathways and processes for eligible children. All children on the bicillin programme are being

reviewed to determine whether they are eligible for referral to AWHI. To date, all eligible children

who have been identified through the school based swabbing programme have been referred.

Referrals to date are detailed in the graph below.

0

4

8

12

16

20

Child Health Referrals to AWHI (n)

Jan - Feb 2014

Auckland Regional Dental Service

Oral Health Arrears Target

A child is considered in arrears if they have not been examined within more than one month outside

their recall period. The Ministry of Health has a target of 10%. The arrears at Waitemata are

currently 8.3% and at Auckland 6.1%, compared to July 2013 where rates for Auckland were 20% and

Waitemata 18%. The results above differ to the scorecard reported result as arrears fluctuate daily

and reports change according to timing.

This graph demonstrates the improvements in arrears rates from October 2009 to February 2014.

The MoH target by June 2014 has been increased to 7% (93% children seen on time). All areas are on

track to achieve the new target by June 30.

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Child Health Redesign

Implementation of the recommendations identified in the Child Health Redesign continues. Key

achievements this month include:

Single Point of

Entry

� The entry pathway has been completed

� A meeting has been held with all team leaders and charge nurse managers to

discuss implementation

� Processes and systems that will support implementation are nearing completion

� The service is actively engaged in the e-referral project

� ‘Go Live’ has been scheduled for the 28th

April 2014

Care Co-ordination � Pre-evaluation questionnaires have been completed

� Initial feedback from clinicians participating in the pilot indicates that there are

significant benefits in the model (e.g. reduction in children lost to follow up) and

improved engagement with families

� A post-evaluation session has been booked for the end of March 2014

School Based

Services

� A stocktake of services provided within school has commenced

� The plan for transition the bicillin programme from Home Care to Child & Family is

progressing within identified time frames and a ‘bicillin champion’ has been

identified from the public health nursing team

� An in depth review of services provided to each secondary school is underway. This

involves the Clinical Nurse Specialist for Youth Health visiting each school with the

allocated public health nurse.

Clinical Pathways � Work continues on developing both the continence and ASD pathways

� Marinoto have agreed that the ASD pathway will work across both services and the

feasibility of developing a joint assessment clinic will be explored

� A working group has been convened to look at the development of an allergy

pathway (due to clinical interest)

Future Service

Framework

� Child Health IT Governance Group has been convened

� A process for defining the integrated teams has been determined and members of a

working group have been identified

ADHB-WDHB Women' Health Collaboration

The CD for Gynaecology and the Operations Manager for Women’s Health are on a collaborative

group working with ADHB and community GP’s to improve the clinical pathway for women referred

with abnormal uterine bleeding.

Midwifery Conference Presentations

Four presentations were accepted by the NZCOM conference committee from the community

midwifery team for presentation at the annual conference at the end of August. The theme for the

conference is “Midwifery relationships in bridging the gaps” and how the sectors of primary,

secondary and tertiary work together.

The presentations accepted are:

• Te Aka Ora (the WDHB model of care for supporting vulnerable women and families in

pregnancy);

• Diabetes in Pregnancy model of care at WDHB;

• Community Midwifery Liaison role;

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• Pacific Island interface with maternity services specifically the antenatal drop-in clinic at

West Fono and the engagement with Pacific Island churches.

Financial Results


Revenue

February Revenue continues to be earned at a lesser rate than budget because the budget assumed

additional revenue to reflect an increase in children being transferred from Starship to Rangitira

($63k per month, $500k unfavourable YTD). In addition the pricing error on Colposcopy also

continues, with a further $63k per month unfavourable variance.

Favourable offsets in February included additional IDFs passed on to Maternity ($92k), and a one-off

accounting adjustment of a release of prior year accruals.

The year end forecast assumes continuation of the Colposcopy and Starship unfavourable variances,

as well as a shortfall on Dental revenue from CMDHB for additional staff and Operational costs

oncharged under the SLA for the new service model.

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Personnel Costs

Medical – February saw continued favourable variances on medical costs, with a significant

underspend of $226k. This is due to a combination of SMO vacancies in Child Health and Women’s

Health, however recruitment into these roles is currently underway, and all but 1 FTE are expected

to be filled by the end of June 2014. Up to this time however the underspend is expected to

continue, and will result in unbudgeted locum costs being incurred to cover acute duties.

Nursing – Nursing costs for February were favourably affected by the reverse of an accounting

adjustment in January; however YTD the result is unaffected and is close to budget. There have

been high levels of vacancies through the year in Nursing, but these have been offset by incurring

higher penal rates and allowances than were originally anticipated. Recruitment of additional staff

will occur in the final months of the financial year in preparation for the winter Roster in Rangitira

ward and in the SCBUs, which has impacted on the small overspend forecast for year end.

Allied Health – Two savings initiatives have impacted on allied health recruitment, being the Child

Health redesign process still underway, and the delay of recruitment of Dental Therapists until the

New Grads were available in the New Year. A total of 22 FTE began work with the Dental service

over January and February.

Administration – The Administration budget includes a total $330k saving line which has impacted

unfavourably by $238k on the Administration performance to budget YTD. This has been offset by

vacancies from the prior year which took several months to fill, influencing the results favourably

earlier in the year.

Note: No vacancies for clinical positions are being held as a cost saving measure.

Other Direct Costs

Outsourced – unbudgeted locum costs incurred to cover SMO vacancies as noted above have

reached $210k for the YTD, and are expected to continue to grow as the vacancies will only be filled

in June 2014. In addition there has been a one-off cost of $87.5k relating to outsourced support for

savings initiative implementation.

Clinical Supplies – The Clinical supplies budget includes a savings target of $900k which will not be

achieved in this financial year. Other options to make savings are being investigated to mitigate this.

In addition to this are overspends within the Dental Service where treatment volumes have been

123% of prior years’ delivery, due to a combination of additional enrolment volumes and also due to

an increased focus on catching up on arrears. This is expected to continue throughout the

remainder of the financial year. The two variances together result in the full year forecast of $1.6m

overspent in this area.

Infrastructure – The change from NZ Post to DX Mail resulted in an increase in postage costs for

CWFS, YTD this has reached $72k, and this is expected to reach $104k by Year End.

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Mental Health and Addiction Services

Service Overview

This division provides specialist community and inpatient mental health services to Waitemata

residents. It is also provides community alcohol, drug and other addiction services, and forensic

services to the northern region. The group is managed by Helen Wood with Clinical Director Murray

Patton for Mental Health and Clinical Director Forensic Services, Jeremy Skipworth.

Scorecard

Health Targets Better help for smokers to Quit: 96%

The service continues to perform above target but is slightly lower this month. This is due to one

person, during the process of two transfers, being missed for a 2nd and 3rd set of questions about

their smoking status.

Shorter Waits in ED: 77%

High bed occupancy and acuity in both adult inpatient units continues to impact on timely access for

admission. One of the impacts of high occupancy is the flows back into the Emergency Department

and waiting times for admission after assessment has been completed and consequently some

extended stays in Assessment and Diagnostic unit (ADU) in NSH.

Quality Complaint response time: 17 days

The average number of days to close complaints was twice the rate of January (8 average days to

close). This is however attributable to one complaint, requiring a detailed investigation and response

which required review by CEO as well as the Board Chairman. It remained open from December

2013 to February 2014. There were 10 open complaints during the month of February, compared

with 8 in January 2014.

Seclusion in Adult Inpatient Units

The time in seclusion from previous reports has increased as has the number of episodes; the bulk of

this increase is related to the very challenging behaviours of three specific people i.e. 12 of the 16

seclusion episodes involved 3 people.

Acute Readmission within 28 days

The readmission rate remains high at 14% compared with National KPI targets of 10%. The period

reported on has seen high occupancy levels (99%). The level of pressure for beds resulted in a

number of early discharges, which is likely to have impacted on the readmission rate.

Human Resources Annual leave over 75 days.

Proactive leave planning is occurring with those people with extremely high annual leave

balances. There are 11 people with leave balance accrual of over 3 year’s entitlement. Some of

group took big periods of leave during January and February. We had a particular focus to get

people on holiday for the summer which has had a big impact. The service was also on

minimum staffing on 7th February to allow for the 4 days HCC upgrade. Annual leave taken has

been greater than annual leave earned for the past 3 months.

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Service Delivery – Productivity Occupancy and Average length of stay:

The waiting list for Forensic Services has reduced from an average of 14.5 during 2013 to an average

of 6.5 so far in 2014, and is currently at its lowest level in recent years with only two prisoners

waiting for admission. Although the commissioning of five additional beds in the Wellington Region

for Auckland patients has contributed to this dramatic improvement, the reduction has also been

the result of sustained efforts by clinicians across the service.

Occupancy continues to be very high for Adult acute units (at 99% for February and into March).

There is a constant review of people in beds, alternatives being found to enable new admissions.

Koromiko House provides contracted respite for the North Shore and Rodney areas. The occupancy

rate for February was 98.4%. Koromiko House (7 beds) has directly felt the impact of the pressure

both on Taharoto beds and the North Shore Emergency Department as Koromiko receives some

direct discharges from North Shore Hospital. During February the occupancy rate for Piri Pono (5

beds) was 56%. This is our newest community based acute residential service and is gradually

increasing its occupancy. Te Kotuku Ki Te Rangi (Respite West Auckland – 6 beds), Feb occupancy

rate was 73.21% Average length of stay is lower for February at 20 days. The data for January showed as 35 days.

This is due to a person being discharged to a high level community package of care who had been in

the unit for 584 days. Length of stay is calculated at the point of discharge.

Waiting Times/ Access Rates

All services are meeting national waiting time targets for non-urgent face to face

contact/assessment. Child and Youth services are making some progress to achieving the end

of year 3% access target.

The measure for access to youth alcohol and drug services still requires changing of the age

band – the band 0-19 reduces access level for the group where as it should be 12- 19yrs olds.

The regional target for access to Youth Alcohol and Drug Services for 2013/14 is 1% of the youth

population aged 12 – 18 years of age, increasing to 1.5% in 2014/15. Clients are included if they

receive at least one face to face contact. In the period 1 July 2013 to 31 January 2014 CADS saw new

217 clients aged 12 – 18 years and the Non-Government sector saw 26 clients in WDHB. The total

was 243 clients or 0.4% of the target population.

All other services are performing well against these measures.

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Scorecard

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No. Deliverable /Action – Prime Minister’s Youth Mental Health Project On

Target

1 Refine data collection systems and collect baseline data for the percentage of

youth discharged from CAMHS and Youth AOD services into primary care being

provided with follow-up care plans, and for consult-liaison sessions delivered by

secondary care to primary care, and set targets by June 2014. The impact of these

practices will be reviewed by June 2015

x

2 Establish baseline for youth access rates to specialist alcohol and drug services and

develop plan to meet the target of 1.5% x

3 Supporting families by developing services for children with parents with mental

illness and addictions by June 2014 and ensure access for the parents to parent

education (e.g. Triple P and Incredible Years) - ongoing. �

No. Deliverable /Action – Mental Health Service Development Plan On

Target

4 Complete a stock-take and gap analysis and develop a three year plan, based on it –

September 2013 completed

5 Collect baseline data for number of consult-liaison sessions delivered by secondary

care to primary care, and set targets by June 2014 On-going

6 Implement the GAIHN integrated care pathway for depression On Hold

7 Ensure links to Whānau ora are made through specific project work �

8 Establish a reporting mechanism to reflect employment status of service-users and

develop an integrated plan to increase opportunities for employment in alignment

with MSD services and welfare reforms (links to local and regional KPI work)

�

9 Meet the wait time targets for non-urgent mental health services �

10 Full implementation of Stepped Care across adult clinical services, and increased

access to talking therapies On-going

11 Establish an inter-agency steering group to develop a local suicide

prevention/postvention action plan

Starting Q4

12 Contribute the mental health perspective to a Maori clinical governance structure

With Maori

Health

13 Ongoing provider arm services reviews �

No. Deliverable /Action – Other On

Target

14 Work towards zero wait times for maternal mental health referrals from DHB

maternity services and lead maternity carers �

15 At least 200 DHB mental health and addiction service practitioners to complete

CALD cultural competency courses within the year 2013/14 �


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Deliverable /Action Prime Ministers Youth Mental Health Project

3. Supporting families by developing services for children with parents with mental illness and

addictions by June 2014 and ensure access for the parents to parent education

COPMIA stands for “Children of Parents with Mental Illness and/or addiction”. This group are at risk

of developing mental health/addiction problems in the future. Whilst NZ research is limited, the

literature identifies that 1 in 5 Australian young people live in families with a parent who has a

mental illness and it is known that children with depressed parents have a 3-fold increase in

depression, anxiety and substance dependence. Building resilience can make a difference for the

future of children who are identified as vulnerable. A stocktake of our local services in 2013

identified the following rates:

These numbers are likely to be an under-representation with adult services finding it challenging to

identify children and additionally those who may be vulnerable. Work is continuing with Child and

adolescent and Adult Services to raise awareness of COPMIA and link with current resources that

are available. Currently we are proposing that:

1. A suite of COPMIA resources be made available to all mental health services group staff.

2. A Child and Adolescent mental health service liaison clinician will be identified for each

adult community mental health team within Waitemata DHB (including Cultural services).

The liaison clinician can be accessed by the Adult Services Clinical Co-ordinator for each

team for consultation and advice when working with families.

3. Group programmes need to be purchased by the funder (as per ADHB contracts) to

promote the resilience and wellbeing of children and adolescents of Adult service users.

This proposal is in joint mental health funder and provider new investment priorities list.

4. Roles/staff in Adult Services and CADS need to be specified for the development and

implementation of COPMIA pathways and ongoing education of staff. This needs to be

developed via Clinical Governance team.

Mental Health Services Development Plan

5. Collect baseline data for number of consult-liaison sessions delivered by secondary care to

primary care, and set targets by June 2014. The Northern region has tested a mechanism for

collecting this data and will go to full implementation in Child and Youth services (including youth

AOD) from 1 April’14. We are leading the country in this work. Some adaptation and testing is

Adult Community Teams Clients who are Parents with

Children living with them

Marinoto Child and

Youth Clients who are living

with a parent with mental

illness

29%

71%

Parent

with

mental

illness Not

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required for Adult services (including CADS) before we can move to full implementation for all

services. We plan to focus on that next stage in the final quarter (April – June).

7. Ensure links to Whānau ora are made through specific project work. Clinical staff from Whitiki

Maurea and the Adult West community teams are starting to utilise the Whanau House facilities to

see consumers. More work however needs to be done to come to commonly agreed practical

approach for i) enhancing existing mental health contract work provided through whanau house

and our services and ii) having a common ground for tangata wha iti ora who are in common with

both services. Liaison work has been occurring from Whitiki Maurea staff.

8. Establish a reporting mechanism to reflect employment status of service-users and develop an

integrated plan to increase opportunities for employment in alignment with MSD services and

welfare reforms. Three very successful workshops have been held with all local NGO providers

with employment related contracts funded by ADHB and WDHB, Funding team, employment lead

for WDHB provision and GM Mental Health group WDHB. There is a high level of enthusiasm for

aligning our approaches, getter better value from contracts, strengthening network and

collaboration between contract providers and attempting to get better contract alignments with

MSD. A joint proposal from this group is going to Waitemata Stakeholder group (WSN) for support

for development and practical gains in this area (next step to having a coherent plan for getting

better outcomes for people in relation to staying in employment, returning to work, coming off

benefits or accessing training /education).

13. Ongoing provider arm services reviews

i) Review of Administration services – A full review of the MHSG group administration structure has

been completed. A six monthly review of the new structure is scheduled for May 2014.

Issues reported to date: Marinoto West have reported a negative impact due to the reduction of

1 FTE. However upon investigation it appears that the impact is connected to staff performance,

rather than the FTE reduction. The Mason Clinic was the highest area affected with the reduction of 5.63 FTE –, regular meetings

to discuss the impact of changes are assisting with implementation. No major issues have been

highlighted to date.

ii) Review of Acute community services

Work to date includes extensive consultation with staff who provide this service, review of

international literature and referencing local proposed changes in both CMDHB and ADHB. A

survey of the work distribution with regard to acuity demands has been completed across the five

community teams. The information will help develop the proposal for the Community Acute

Services Plan. This Acute Service Review has reached a point where a formal proposal will be

presented to staff in late March. Staff reports have identified ongoing stress in relation to

workload, particularly in the west HBT service. Meetings have been held with the service and a

transitional plan identified to manage workload prior to the implementation of proposed changes

following the acute services review. The roll out of the full Model post staff feedback is expected

to occur in May and June 2014. Some of the proposed changes to rosters and hours of operation

will still be taking place in June and July 2014.

15. At least 200 DHB mental health and addiction service practitioners to complete CALD cultural

competency courses within the year 2013/14. Good progress is being made given the range of

training practitioners need to do. For the year to date, 157 staff completed the course (as at 28

February 2014).

Areas off track for month and remedial plans

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1. Refine data collection systems and collect baseline data for the percentage of youth

discharged from CAMHS and Youth AOD services into primary care being provided with

follow-up care plans, and for consult-liaison sessions delivered by secondary care to primary

care, and set targets by June 2014. The impact of these practices will be reviewed by June

2015. Implementation of the guidelines is delayed due to the required guidelines not having

been published by the MoH and Werry Centre. The requirement by the MoH is to implement

these follow up transition guidelines. We anticipate receiving a full update from MoH on 11th

April. The tools to measure consult Liaison to primary care (GPs and Education) are being

established in the Northern region and due for full Child and Youth mental health and

addictions services roll out from 1 April.

2. Establish baseline for youth access rates to specialist alcohol and drug services and develop

plan to meet the target of 1.5%: current measurement is against 0-19 age group where the

target group is 12-19. Discussions are being held with MoH to rectify the definitions for this

group. Current reporting provides an inaccurate picture because of inclusion of 0-11 group in %

totals – implies lower access than is actually occurring for the group it is intended to target.

Other Highlights

Youth AOD exemplar services CADS was successful in the second round of tendering for a Ministry of Health “Youth Alcohol and

Drug Service Exemplar” Request for Proposals (RFP). This RFP was part of the Prime Minister’s Youth

Mental Health Project and aims to improve services to young people with substance abuse

problems. The proposal is targeted at improving the interface between CADS “Altered High” youth

service and primary care providers including general practitioners and school based health clinics. It

aims to increase the volume of young clients that can be supported in primary care as well as

increasing referrals to CADS “Altered High”. The Ministry targets the project in particular on Maori

and Pacific youth, living in low social economic areas. The RFP includes three full time staff. The

“Youth Alcohol and Drug Exemplar” initiative includes six projects in total nationwide (of whom

CADS is one). Results will be widely disseminated to stimulate the development of Youth Alcohol and

Drug Services in other DHBs.

Muslim Mental Health awareness and collaboration project

This project is underway to communicate with Imams to develop a clear pathway for community

mental health teams to access Muslim cultural support/ guidance. The project is led by a staff

member, Khalid Shah, and supported by Asian Mental Health Services and the Asian Mental Health

and Addiction Governance Group. The goal of the project is to increase Imams/ community leaders’

understanding of available mental health services, and their knowledge of how to access these

services. This has involved building relationships with Muslim community leaders/ Imams and

developing the content of mental health awareness workshops to be delivered at the local Mosques.

This work will support greater awareness of when and how to refer to WDHB services and to link

with support/ education activities that operate through Mosques and other Muslim social services.

Renewal of the Pacific Gambling Contract for Takanga A Fohe.

We received confirmation week of 17 March that our proposal to keep the contract as part of a full

open RFP process, was successful. In the RFP, the service asked for 5 clinical FTE and 2 Public Health

FTE. These were granted in full at the maximum price that the Ministry set in the RFP. MOH have

indicated that they would move to the contracting details in the month ahead. For now, Takanga A

Fohe are excited but mindful of the other services that have not been successful and the need for

the service to maintain good relationships with them.

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Facilities updates 1) Mason Clinic Refurbishment: Resource consents are being sought for the building of a unit on

land leased from Unitec for the purpose of decanting current patients of the forensic service and

enabling remedial works to proceed for our leaky buildings. An arborist report has been

received and soil report is pending. The panel reviews resulting from Expressions of Interest

(EOI’s) for Architect and Cost Consultant have been completed and requests for Proposals (RFP)

for three architect companies and Cost Consultants close 21 March. The design brief/outline

specification for the Tanekaha facility was approved at the December 2013 Steering Group

meeting and the architect that will be appointed as a result of the RFP will complete the concept

design options to the end of concept stage.

2) He Puna Waiora: An implementation plan identifying a range of current operational areas for

review and change has been finalised by the Steering Group. Working groups will be established

involving inpatient, community and NGO staff over the next two months. These groups will be

responsible for reviewing existing processes with the aim of making improvements/changes

which can be transferred to He Puna Waiora.

Communication strategies have been established between Carmel Collage and WDHB. A weekly

meeting occurs between the construction company and facilities manager of Carmel Collage and

these have been progressing well. Garth Whittaker, Helen Wood and Christine Allen (Principal)

will meet monthly commencing in March. There is a staff intranet site which has the live camera

linked to it and construction updates. The project sign board naming the project and all parties

involved has been approved by the CEO and will be erected on the building site shortly. A mail

drop for the residents and businesses of Shakespeare Road will occur week beginning 24 March.

The Communications team have been involved to develop the content. A presentation was given

to the Community Engagement forum last week.

A tree planting ceremony was held on the 26th March. Maggie Barry, National MP, Dr Dale

Bramley, CEO and Dr Lester Levy, Board Chairman attended together with Senior Management,

Lead Clinical Roles for Mental Health Services and some of our NGO partners.

Recruitment and Workforce

Child and Youth Teams: The Youth Consumer Advisor has been appointed and begun orientation.

She brings with her some previous experience in youth consumer roles and is also completing

studies in public health. Recruitment continues for a replacement Maternal Mental Health

Consultant and for a Child and Adolescent Consultant for Marinoto North. The SMO group are

pulling together to provide sufficient cover in the meantime. The recruitment for the new acute

perinatal community specialist roles is underway. This is a regional recruitment process. WDHB will

have an additional .6 SMO and 3.29 clinical fte. These roles will need to work flexibly and cover

weekend and some out of hours work as part of a regional process.

SMO Job Sizing for Adult, Child and Youth and Cultural Services: The service size has been agreed

and the process will be now to formally notify SMOs individually of the outcome of this process. For

Adult Services, the Service Clinical Director, Mike Ang, and Operations Manager, Don Mackinven will

formally notify all SMOs of their individual job size offer and will meet with them to go through their

work plans. A similar process will start with the other services. It has been agreed that where there

is a shortfall of hours, all existing staff will be offered new service size. Any new and additional fte

will need to be added over time as funding allows.

Key Issues Coming UP

Wiri Prison Impact for Forensic Services

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Waitemata DHB has provided the Ministry of Health with an analysis of anticipated demand when

the private prison is opened in Wiri next year. The prison will open in April 2015 for 960 male

prisoners. Although the Forensic Service anticipates the need to provide specialist mental health

services to these prisoners, the Ministry has yet to provide a commitment to the resources that will

enable this. In addition to a dedicated prison team (10fte) there will also be a need for between 5

and 10 additional inpatient beds. As these beds will not be available in the northern region in the

short term, we believe the Ministry will need to explore dedicated forensic beds elsewhere in the

country to serve this population until such time that they can be accommodated at the Mason Clinic.

MoH senior leadership (Cathy O’Malley) is visiting Mason Clinic on 11th April and this will be one of

the topic areas she is interested to discuss with us.

High and complex needs business case

The Board gave approval to develop a detailed business case for the provision of two community

residential options for around 16 people. We have started work with Funding and planning team

and aim to have business Board approval in May. This would free up bed capacity from those who

require a high level community option, not an acute bed. The total impact would aim to free up to

potentially 16 beds across both units. Consideration of service users at Mason Clinic needs to be

included so the full 16 beds may not be available solely to Adult Inpatient Units.

Increase in child and youth referrals in North Shore & Rodney

Marinoto North has reported a 25% increase in referrals as compared to February last year. This has

implications for meeting service demand and wait time targets. Analysis indicates that for the next

quarter Marinoto North will need to offer 400 Choice appointments but currently only has capacity

(staffing and facilities) to offer slightly more than 300. We are currently seeking solutions to address

this such as identifying alternate clinic space and anticipated filling of vacancies.

Understanding the nature of demand change is an important feature of finding solutions. Referrals

are a mix of new to service and those returning for a “top up” in Treatment. The choice and

partnership model allows for easy access, easy out and easy back to enable a more episodic

approach on an as needed (just in time) principle rather than families staying in treatment or on

caseload for long periods (“just in case” model). For the Marinoto North youth team (up to 18yrs or

still at high school), 30 referrals out of 75 in February were new to service. North Child team (up to

school year 8) 16 out of 36 referrals were new and Rodney (0-end high school /18yrs), 20 out of 39

were new.

The attached graph compares referral sources between February 2013 and February 2014, and

shows some increase in referrals from GPs, within WDHB, schools and self.

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59 of 107


Financial Results

Comment on Major Financial Variances

Revenue

The favourable revenue result of $247k YTD is driven by unbudgeted contracts signed after the

budget was set amounting to $279k YTD and $258k of additional revenue received because of a

delay in commissioning alternative services to the existing adult mental health respite and inpatient

sub-acute facilities. The revenue for the latter ceased in September as the community alternatives

are now up and running.

An unfavourable variance of $325k YTD arising due to reallocation of Forensic demographic funding

to Capital and Coast DHB to fund 5 Forensic beds partially reduces the positive impact of the

additional revenue referred to above. The full year impact will be $490k adverse.

All of these items are factored into the full year forecast position.

Personnel

Medical personnel expenditure is favourable to budget by $695k YTD because of a CME adjustment

($30k), better coverage on the registrar after hours on call roster ($209k) and vacancies. Vacancy

savings through the payroll are partially reduced by costs realised in outsourced services ($286k) due

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to employment of a locum and payment to the University of Auckland for shared employment

arrangements.

Favourable variances for the year to date in allied ($652k) and nursing ($832k) are also mainly driven

by vacancies. Positions not in scope for savings are actively being recruited to. The positive result in

nursing is to some extent attributable to improved acuity management on the inpatient units. $77k

of the variance is due to the remedial works at the Mason Clinic taking place later than planned in

the original business case.

Management/Admin is adverse $213k YTD due to delayed implementation of the administrative

review savings initiative and one off exit costs associated with the project. The project is now fully

implemented.

The full year forecast for all personnel groups reflects the position as at the end of February

incorporating known changes to staffing levels.

Other Direct Costs

The unfavourable variance of $833k YTD in outsourced services relates to unmet budget savings

($720k) and outsourced clinical staff budgeted for in personnel. These variances are partially

suppressed by an under-spend on forensic step down beds of $67k. Variances connected to unmet

budget savings and forensic step down beds are forecast to continue at the same rate for the

remainder of the year. Outsourced personnel costs are forecast to rise in the last four months of the

year due to employment of two additional locums in adult mental health and unbudgeted project

costs.

Notable explanations contributing to the $308k overspend on infrastructure and non-clinical

supplies and forecast year end result of $541k unfavourable are late billing (YTD $32k), security

services for watches in adult mental health (YTD $57k) and unmet budget savings (YTD $200k). In

addition, $67k of cost has been realised to conduct a relapse prevention in psychosis education

project, which is completely offset by additional revenue.

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Surgical and Ambulatory Services and Hospital Operations

This Division provides elective and acute surgery to our community encompassing surgical specialties

such as general surgery, orthopaedics, otorhinolaryngology and urology, and includes outpatient

clinics, operating theatres and pre and post-operative wards. ICU and radiology are with this service.

The service is managed by Cath Cronin. The Head of Division Medical is John Cullen, Head of Division

Nursing is Kate Gilmour, Head of Division Allied Health is Tamzin Brott.

The Group Manager of Hospital Operations is Leith Hart.

Headline News

We are very pleased to announce the appointment of Michael Rodgers as Chief of Surgery, Surgical

and Ambulatory Services. Mike is an Upper Gastrointestinal and General Surgeon who has worked

at Waitemata DHB for10 years. He has previous senior clinical roles including Clinical Director,

General Surgery at Waitemata.

Kate Gilmour has been permanently appointed to the Head of Division, Nursing Surgical and

Ambulatory Services. Kate has been acting in the role for the past 12 months and her achievements

have been well illustrated in this report over that time

Richard Harman has been appointed Clinical Director of General Surgery. Richard has been acting

CD for the last few months and is the lead surgeon for Breast Services and Breast Screen Waitemata

Northland.

Dale Shewan has been appointed as Operations Manager, Orthopaedic Surgery. Dale has relocated

from Tauranga. She brings great experience from similar roles in both the public and private sector

We welcome Mike, Kate, Richard and Dale to these senior clinical and professional leadership roles.

Scorecard

Health Target

Better help for smokers to quit is above target at 97.5%.

Elective Surgery Volumes

The Waitemata DHB Surgical Programme (S&AS, CW&F and ESC) remains on track to achieve

elective volumes to meet MoH target year to date. However it is important to note that we have a

very tight schedule to meet the 30 June Health Target.

ESC has achieved on average 81% of performance to surgical health discharge target from 30

September to 2 March. Surgical and Ambulatory Services is over delivering in a planned approach

and achieving on average 111% delivery to surgical health discharge target.

Radiology

For January the Radiology wait time indicator levels were 70% of patients received their CT scans

within 6 weeks and 21% received their MR scans within six weeks. These were down from 90% and

32% respectively for December. The target achievement levels set by the Ministry for these

indicators are 85% of CT scans within 6 weeks and 75% of MR scans. The January waiting times have

been impacted by the statutory holiday period and reduced booking capacity. The MR throughput

was further reduced by the build work underway for installation of the second MR scanner. The

contract with the Ministry of Health to reduce the tail of patients waiting longer than 21 weeks,

which was largely achieved through outsourcing, was completed in mid-January. It is expected the

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benefit of this additional Ministry funding on the wait times will be reflected in improved February

results.

ESPI 1, 2 and 5

We have achieved compliance for February and are on track for March. The majority of specialty

units are progressing well to 100% compliance for ESPI 2 and 5 for five month treatment times and

making inroads into the 4 month indicator.

Focussed work is continuing with both orthopaedic surgery and ORL. These units continue to be at

risk of non-compliance. This is largely attributed to specialty surgeons’ hours and clinical demand

that exceeds the specialty mix within a surgical unit. This is being addressed and we will align

population demand to Waitemata DHB service capability.

Quality

Twenty one compliments were received by surgical services in February.

The service received 16 complaints in February (12 received at the same time last year) and achieved

a complaint response rate of 18 days. The delay in the response rate was due to two complaints

that required some time to investigate and be responded to in writing. However both patients were

kept informed while their complaints were being investigated.

The new Informed Consent Policy and Consent to Treatment are now published as controlled

documents. The policy and form have been developed over a number of months with wide

consultation. The form is available and can be ordered through Oracle. The policy is the formally

approved policy considered interim for 8 months to allow additional feedback. Staff update and

training are currently being organised by their Managers with a particular focus on NSH and WTH

theatres.

Provider Arm Did Not Attend (DNA) Project

Cath Cronin is the Lead GM for the DNA project for the Provider Arm. The project is tasked to

complete a detailed review to understand why the DNA rate for our Maori and Pacific Island patients

is disproportionately high in comparison to other ethnic groups. The project lead, Lael Meredith is currently working with staff from the Provider Arm, Cultural

Support Teams, Planning and Funding, Business Support and Primary Care to improve reporting on

DNAs and develop options, which can be tested and implemented to improve engagement with

Maori and Pacific patients and reduce DNA rates. Details of patient and health provider questionnaire findings, data analysis and literature review

have been collated and are being socialised with project steering and working groups.

Recommendations are being developed for key areas identified. Initial findings are indicating that

we will be in a position to identify areas to improve our services to both Pacific Island and Maori

patients and whanau.

The February DNA rates for the provider arm are below: DNA Rate % - Feb 14 S&AS Medical CW&F ESC WDHB

FSA DNA Rate total 11.7% 12.2% 10.9% 14.8% 11.9%

Maori 32.3% 26.3% 22.1% 25.0% 27.0%

Pacific Island 25.0% 22.1% 18.4% 15.4% 21.3%

Follow Up DNA Rate

total 9.3% 9.2% 11.7% 7.8% 9.5%

Maori 24.0% 22.1% 17.9% 20.0% 21.9%

Pacific Island 17.9% 18.5% 27.5% 12.5% 20.0%

WDHB 10.0% 10.0% 11.4% 10.9% 10.3%

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Scorecard

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Service Delivery

Intensive Care/High Dependency Unit and Outreach

The patient and family experience project has commenced utilising a steering group and subgroups

for the four core areas: patient and family information, patient experience in ICU (patient

diaries/surveys), bereavement and long term follow-up, and follow-up post discharge from

ICU/HDU.

It is pleasing to be represented at the national Australia New Zealand Intensive Care Society

conference in Christchurch with a poster presentation from the Outreach Team Leader and a verbal

presentation from the Clinical Educator.

Surgical Wards

The surgical wards have all updated their quality plans which include the agreed quality and safety

markers falls, pressure injuries, hand hygiene and CLAB.

Quality Rep study days have commenced and had a focus on documentation this month which

included the redesigned Nursing documentation and a ward transfer form. The pilot is now well

underway.

Infection Control:

CLAB

• ICU/HDU - 166 CLAB free days

• WARD 8 - 475 CLAB free days

• Ward 4 - 560 CLAB free days



ESBL incidence and prevalence remains high.

Strategies continue:

• Admission and discharge screening

• Nursing ESBL patients on one half of each ward

• Appropriate signage has been put up to mark dedicated ESBL areas

• Information brochures/sheets have been updated/created to be given to patients and their

families

• Infection Control will map each ward’s ESBL positive patients by room to identify any areas that

need appropriate cleaning/decontamination - there has been clusters in D room opposite

communal toilets

The surgical wards have advertised and Ward 7 has appointed a 6/12 fixed term appointment of a

housekeeper from current resource to support and supplement the nursing, domestic and hostess

services. As part of a ward team the housekeeper is responsible for maintaining a safe and

comfortable environment, ensuring that all patients and visitors are welcomed and experience an

efficient, effective and comfortable service.

Hand Hygiene

• Bare Below the Elbows continues to be business as usual for the Surgical Wards

• Gold auditor training was completed this month which will enable those trained to be able to

intervene and educate/provide feedback on the spot to correct practices. It also enables them to

have the ability to communicate immediate feedback to staff for good hand hygiene practices

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• Hand hygiene compliance remains unsatisfactory – there will be discussion at upcoming General

Surgical and Orthopaedic business meetings to discuss barriers

• Healthcare Assistant training will be carried out to improve their practice and to empower them

to discuss good practice with their colleagues.

Falls

Falls risk assessments were completed for 97% of patients with a falls risk on the surgical wards.

Strategies have been implemented to increase completion within 8 hours of admission.

There has been one fall with fracture this month.

Friends and Family

Surgical and Ambulatory Services have a Net promoter score of 67% with a total of 1,913 responses.

Orthopaedic Early Recovery After Surgery (ERAS) Collaborative Project

Waitemata DHB clinical leads and project working groups have been established for both the acute

fractured neck of femur and elective hip/knee pathways as part of the National Orthopaedic

Collaborative project. Change concepts have been identified and driver diagrams developed as per

the framework and improvement methodology set out by the Ministry of Health. Members of the

project group are participating in the National Collaborative Learning Sessions and National WebEx

meetings provided by the Ministry.

ERAS interventions such as the standardised multimodal anaesthetic/analgesic and surgical

protocols are under development for both the acute and elective pathways. Change ideas are being

tested at the local level and education sessions are being provided across both the North Shore

Hospital and Elective Surgery Centre sites. Current patient information and staff documentation is

under review and will be adapted to include the ERAS principles. Data measures are being collected

and will demonstrate progress in ERAS compliance and outcome measures throughout the

implementation of ERAS.

Design Innovation

Ward 8 planning continues with the Concept Design due to be signed off mid-March 2014. The

design provides for 6 single bedrooms, 3 doubles and 4 four bed rooms. This includes two special

(bariatric) single rooms as well as a 4 bed high observation area (details to be confirmed). Once the

concept design has been agreed, an estimate of project costs will be obtained and planning will

progress to preliminary design, determining the exact location of each room within the ward.

The Project Team undertook a site visit to Greenlane Hospital Eye Ward to review room layouts and

staff base options and will be visiting Southern Cross in the next few weeks. In addition,

investigation continues into potential innovation to be utilised on the ward, working closely with IT

and Research and Innovation.

Leadership

The four Surgical Charge Nurse Managers attended the first cohort of the CNM Leader Development

Programme LEADING QUALITY. This programme will build leader capability, and therefore influence

and strengthen performance centred on quality care and patient outcomes in wards. Feedback and

insights from the first cohort will be utilised to evaluate the course for the second cohort.

Ward Productivity

The Surgical wards have had approximately 890 surgical cases through the surgical wards this

month; approximately 460 of these cases were acute.

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Theatres North Shore Hospital and Waitakere Hospital

The interim consent policy has just been released and is a major focus for the OR. An education

plan is being developed which includes FAQ sheet and drop in sessions with legal

representatives over the next 2 weeks to ensure all staff have a good understanding of the

changes to the policy.

February was another busy month for NSH theatres with an additional five sessions in addition

to planned sessions for both acute and elective surgery.

WTH surgical unit has been busy recruiting new staff to fill FTE vacancies. Orientation of the

new staff is now well underway.

Patient Service Centre

Surgical and Ambulatory Services Operational Team restructure is now complete and the

Patient Service Centre (previously Booking and Scheduling) has been established with a focus

on supporting the patient journey and patient experience (Everyone Matters). An initial test

stage for Patient Focussed Booking (PFB) commenced 10 March within orthopaedics. The first

stage of PFB process enables patients to be involved in negotiating their First Specialist

Appointment. Rollout of Patient Focussed Booking is planned over 2014.

Cancer Care Coordination Update

Huri Perry, our Clinical Nurse Specialist Maori Cancer Coordinator, has been welcomed to our team

with a Powhiri held at Waitakere. Waitemata Cancer Patient survey has been sent out to 441

patients, we have received back approximately 60%.

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Specific deliverables/actions to deliver improved performance will consider: On

Target

A fully functioning Cancer Care Co-ordination service employing clinical nurse

specialists across all tumour streams and including Māori and Pacific

navigators, Faster Cancer Treatment tracking, and a Clinical Lead for Cancer

Care, by 30 June 2014. Cancer nurse co-ordinators will be supported to attend

regional training and mentoring forums.

�

Use Faster Cancer Treatment data reported to the Ministry of Health as

baseline data for service improvements �

Design rapid reporting and telephone communication of results of diagnostic

scans and investigations

�

Re-designed cancer multi-disciplinary meetings consistent with national

standardised processes of access, documentation, communication and care

coordination, audit and reporting in place by 30 June 2014

�

Conduct a baseline survey of cancer patient experience � Collect ethnicity data for Māori and Pacific People at the key Faster Cancer

Tracking wait time indicators as baseline data for 2014/15 interventions to

reduce ethnic inequalities � Plan to deliver required elective surgical discharges for the Waitemata DHB

population in accordance with patients’ assigned priority and within the

appropriate waiting time

�

Ensure plan in place to meet and maintain ESPI compliance � Monitor patient outcomes including complication rate, readmission rate and

infection rates each month by ethnicity

�

Ensure improved Maori and Pacific access to bariatric surgery � Implement electronic referrals for eight elective procedures by 30 June 2014 �

Review numbers of follow ups to ensure match to clinical need with a plan to

discharge patient back to primary care

�

Audit current ultrasound utilisation and relevant back-up to better understand

possibility of incorporating both CT and CT angiogram within same

appointment for TIA patients

�

Implement new Outpatient Service model (staffing, booking & scheduling) � Maintain direct access for general practitioners to a full suite of diagnostic

imaging including X-rays, ultrasounds, fluoroscopy, mammography, nuclear

medicine, CT and MR with a focus on reducing waiting times for ultrasounds

(establish baseline Q1, reduction in waiting times by 30 June 2014)

�

Electronic referral templates, developed by a working group comprised of

primary and secondary clinicians, implemented by 31 December 2013 to

enhance general practitioner access to radiology services

�

Direct referrals by general practitioners to elective booking lists will be in place

for skin lesions, vasectomy, mirena insertions and ring pessaries (WDHB) –

confirm current practice and establish baseline Q1, identify any

enablers/process changes required Q2, implement changes required Q3,

direct referrals to identified booking lists in place Q4

�

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The Waitemata DHB chronic pain management service will work more closely

with general practices through improved availability for telephone and email

contact and by having regular, interactive workshops which will provide a

forum for specialist pain staff to share knowledge with primary care

practitioners to improve the community based management of patients with

chronic pain. The service will operate with a concept of “partnership in pain

management” between the patient, general practitioner and hospital

specialist service

�

Ensure viable elective services units within Provider Arm during 2013/14 � Ongoing provider arm services reviews �

MRI replacement �


Key achievements for month:

ESPI compliance achieved for second quarter (within MoH buffer) Surgical Health target on track for second quarter

Areas off track for month and remedial plans:

Risk areas are ESPI 1, 2 and 5. Focussed work underway as above in commentary

Key issues/initiatives identified in coming months • A focussed review of management of referrals is continuing with successful outcomes to

manage referral timelines, improving the patient experience and working to standardised

guidelines.

• Increased engagement with primary care is planned to increase quality of referrals with

complete patient information.

• Surgical pathway analysis is underway to measure surgical demand/capacity and treat all

patients within 4 months, achieved prior to December 2014 and to sustain this into FY16.

• Daily monitoring of performance to targets and financial management continues to ensure

health targets are met and any potential risks to achieving revenue are identified and resolved

including the additional 166 surgical discharges.

• Clinical Supplies Project continues to improve reporting and timely data on expenditure for

clinical supplies. NSH theatre inventory scanning of imprest items has commenced and the

receipting issues have now been rectified. The Inventory team are working to extend the

scanning to some additional sub Inventory store areas.

• The DNA project is well underway with a goal to have recommendations from our patients and

their families/carers, the provider arm, public health and community providers to ensure we

address this issue with a sustainable outcome of a DNA rate less than 10% for Maori and Pacific

Island populations.

• S&AS has received funding and has commenced the Enhanced Recovery After Surgery (ERAS) to

orthopaedic patients (hip/knee procedures and fractured neck of femur). This project is being

lead by Matt Walker, Michal Kluger and Teresa Wingate.

• Strategies are in place to contain our expenditure and to look for opportunities to continue to

realise savings initiatives within the service.

• Formalisation of appropriate financial processes between S&AS and ESC.

• Commence work to review ESC after 12 months in operation.

• Multiple avenues of work progressing with Cancer Treatment Times. A new indicator has been

agreed of treatment within 62 days from referral. An update will be included in the next report.

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Neck of Femur Fractures (#NOF)

The clinical team with a multidisciplinary focus over surgery, medicine and allied health have

developed the initial work focussed on patients with fractured NOF to a review of the patient

journey from admission to rehabilitation and discharge into the Ministry of Health supported

National Orthopaedic Enhanced Recovery After Surgery (ERAS) Collaborative Project. ERAS

pathways are clinically focused, cost effective, patient driven pathways, with an evidenced base in

improving quality outcomes, teams working across functional, organisational and professional

boundaries.

One important international indicator is the time to surgery in 24 and 48 hours. We are tracking well

within the 48 hour indicator but will continue to measure the time to surgery for 80% of patients

within 24 hours. We would expect 100% of medically fit patients to receive surgery within 48 hours.

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Financial Results

Surgical & Ambulatory Services

COMMENT ON MAJOR FINANCIAL VARIANCES (S&AS = Surgical & Ambulatory Services)

Summary

The February monthly result is $262k favourable and $626k favourable YTD. This is primarily due to

the extra patient activity (108% of plan), and the resulting revenue, being greater than the

underlying additional costs. During the same period the division has absorbed $2.6M of savings

initiatives, whilst $350k of costs relating to prior years have crystallised in the current year. It is

forecast that the current favourable variances offsetting ESC will continue, and move slightly higher,

however this will be directly impacted by ESC as improvements in ESC throughput will reduce

revenue recognition in S&AS.

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Revenue ($3,694k favourable YTD)

The MoH revenue variance YTD is $3.9M favourable, due to YTD elective wies volumes at 119% of

plan –effectively volumes done at NSH instead of ESC.

Included in the MoH revenue variance is an additional $445k unbudgeted MRI/CT volumes due to an

additional MoH funded initiative to reduce waiting times for imaging.

ACC revenue is $280k or 20% below budget YTD. This has improved substantially in the past two

months but is still well below where we would expect it to be. $55k has been recognised at ESC

instead of S&AS and we are doing further analysis on the Orthopaedics ACC Contract overall to

determine why revenue is less than expected YTD.

Expenditure

Medical personnel: ($936k unfavourable YTD)

The main driver is a change in the model of care in relation to anaesthetists’ resourcing of ESC.

Budget costs for anaesthesia are budgeted within ESC as an outsourced service cost. However with

the late change in approach the actual costs now fall into the medical personnel costs in S&AS. The

recharge to S&AS for these costs is recorded in the outsourced service costs line. YTD anaesthesia

SMO costs are $984k unfavourable because of this. Other medical costs are favourable by $48k –

across SMOs and RMOs. FTE are broadly in line with budget.

Nursing: ($168k favourable YTD)

Staffing is effectively at budget, with a small favourable variance. However nursing outsourced costs

are $306k unfavourable as noted below, resulting in a combined $138k unfavourable position.

However given the volumes in S&AS this is a good result.

Allied Health staff: ($495k unfavourable YTD)

The unfavourable $495k YTD variance is in contrast to the actual staffing situation in Allied Health,

which is 1.77 FTE favourable due to vacancies and maintaining disciplined rosters. However, a $424k

savings line, being part of S&AS’s $2m share of budget savings initiatives, to which S&AS is fully

committed and plans to deliver, is included in the Allied Health set of accounts. These savings

initiatives are being actively addressed in all divisions of S&AS and has been absorbed across the

division.

Admin staff: ($387k unfavourable YTD)

Similarly, the unfavourable YTD variance of $387k is created by a $237k YTD savings line in this cost

centre, with the actual planned staffing and costs broadly on budget. Some restructure impacts have

added some costs in this area for management where extra resource was required particularly in the

Patient Service Centre ($120k).

Outsourced personnel: ($497k favourable YTD)

As noted above, the accounting treatment for the anaesthetists working at ESC now reflected as a

credit on this cost line to the amount of $1,584k YTD. Offsetting this favourable (unbudgeted)

revenue is the savings initiative that is not currently being achieved based on the Ophthalmology

Service implementation ($466k unfavourable). Other unfavourable items include Package of Care

costs for surgeons of $183k doing unbudgeted work at WTH awaiting the start of ESC (first 2 weeks

of July) and other claims for some additional sessions; $306k of unbudgeted bureau nursing costs;

$38k of unbudgeted orthotic and hand therapist costs and $45k of unbudgeted Fee for Service Costs

for colonoscopies relating to the Bowel Screening Programme.

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Outsourced services: ($461k unfavourable YTD)

Radiology have incurred $364k unbudgeted costs for MRI and CT outsourced imaging requests

related to a MoH funded initiative to reduce imaging waiting times (this is reflected with $445k in

revenue to offset this cost). Additionally $113k of outsourced ultrasound work has impacted.

Clinical supplies: ($1,685k unfavourable YTD)

Inpatient activity is 108% of plan (acute + elective wies YTD) but expenditure is 110% which indicates

we are unfavourable with planned levels on a volume adjusted basis to the extent of about $250k.

Implant costs for joint replacements are high and will be investigated further.

Infrastructure: ($160k favourable YTD)

A number of items offset each other however the key item is a favourable stock adjustment ($145k).

Post implementation of the inventory scanning system in theatres, we are reviewing the outcomes

to ensure accuracy of our financial transactions.

S&AS and ESC Combined

The combined summary helps off-set some of the larger disparities created by the ratio of budgeted

volumes delivered between NSH and ESC theatres being different to those that have actually

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occurred in the first eight months of ESC’s operation. Overall inpatient activity is at YTD 100% of plan

across the two entities.

Overall YTD revenue is line with budget, with the exception of ACC which is $224k unfavourable.

Further analysis is occurring in this area.

Total YTD personnel expenditure is $1.4M unfavourable, however of the outsourced services the

staffing component is $1.4M favourable – so employee costs are essentially in line with budget.

YTD clinical supply costs are $1.3M unfavourable (5.7%). The main variances are in orthopaedic

implant costs and ESC treatment disposable costs. We will be further investigating the implant costs.

The net result is $173k favourable for February and YTD is $1.4M unfavourable. We envisage that

the remaining months will deliver at budget levels at a consolidated ESC/S&AS level, with a resulting

$1.4M unfavourable full year forecast.

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HOSPITAL OPERATIONS

Service Delivery/Key Issues Food and Nutrition Services

Recruitment and offer made for the vacant food contract manager position.

Laboratory

Regional RFI discussions held to discuss Real Time Temperature Monitoring System. This system will

be used for monitoring of fridges, freezers, incubators, room temperature and areas storing liquid

nitrogen, pharmaceutical storage and blood products.

Security

A pool vehicle was stolen from Waitakere site and vandalism was found to Healthwest building. The

Police are investigating both these issues.

There have been an increased number of calls to assist with aggressive patients.

High number of access cards being issued this month, mainly to house officers and new graduates.

Also over 1,000 access changes made to staff cards to allow access to the new gymnasium at NSH.

Crisis Intervention Training provided by security well received by participants this month, positive

feedback from CADS and new graduates.

Security staff completed 62 incident reports with 40 restraint events reported. One staff member off

for 2 days as a result of injury received during a restraint event.

Security Supervisor at Waitakere has resigned to take up the position of Waitemata DHB Fire

Training Officer, this position is currently being advertised.

Pharmacy

North Shore Hospital Inpatient and Outpatient Pharmacies, and Waitakere Inpatient Pharmacy, have

all fully attained the required audit criteria during the Pharmacy Quality Audit 4 by Medicines

Control, Ministry of Health.

Medication Safety Strategy reporting is now included in the HAC Quality report. Information about

the progress of the electronic Prescribing and Administration system (ePA), as well as the electronic

Medicine Reconciliation system (eMR) is included there. Of note, the eMR system will be available

to the Medical Wards at both Waitakere and North Shore Hospitals as from 3 March 2014, and the

clinical pharmacists will be incrementally increasing the number of medication histories recorded

electronically.

The use of the PHARMAC managed Hospital Medicines List (HML) which was initially introduced in

July 2013 and which is still in transition phase, is being consolidated. Most of the associated issues

have been resolved, and systems are being implemented proactively to ensure that information is

recorded on high-cost medicines that are likely to be audited by PHARMAC (e.g. infliximab).

Surgical Pathology

There is an issue with standard of air extraction in the laboratory. Temporary bench top extraction

units are being used to reduce the formalin fume levels. We are working with Facilities for a

permanent air extraction system.

An additional histology technician FTE is currently being recruited to keep up with volume growth.

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Clinical Engineering

An equipment service programme has been established for routine equipment inspection and

maintenance.

Planning is underway to expand the North Shore Hospital workshop space. This will improve

workflow and service efficiency, with all technicians working in one workshop.

The Waitakere Hospital workshop has been remodelled to accommodate additional staff who are

now on a monthly rotational schedule from North Shore Hospital. The rotation of technicians

through Waitakere Hospital will assist with the increasing workload demand at this site and also

allow staff to gain local knowledge and expertise, thus increasing our ability to cover for leave.

Traffic and Fleet

There is a Northern Region DHB project underway with regards to Fleet Management Services.

Initial scoping for this project is underway.

Staff parking at the main car park building is at capacity most days now by 09:00 A.M. There are still

a number of car parks available at the Shea Terrace staff car park, which has not yet reached

capacity. The reinstatement of the P.M. car park is working well.

The CEO has requested work be undertaken to look at options for more car parking availability.

Clinical Support Services

Operations Manager commenced early February, review currently being undertaken on internal

structure as there are three vacancies in the Management team. There are a significant number of

operational vacancies currently being covered by the outsourced labour force and a plan is being

developed to advertise and appoint to these vacancies.

A master roster is being developed, so this can be compared to the budget in order to contain costs

as we move away from the outsourced labour model. A review of each duty will be made before

recruitment commences to see if we can realise any efficiencies.

A meeting has taken place with Career Force who will be assisting with the Orderly NZQA

qualification and plan to undertake an assessment of staff in April, this should coincide with

recruiting the Training and Quality Manager position.

Training has been identified for the Service Development Coordinators as follows: leave

management and Hazardous Substance and New Organisms (HZNO) Training.

Introduction meetings have been carried out with all contractors including waste contractors (which

the Operations Manager is currently looking after until the Sustainability officer is recruited and

appointed).

Data analysis of Linen Product Catalogue continues for HBL project.

Fuji Xerox site audits have been completed with recommendations of 159 copiers being removed.

Relocations

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Highlight for the month has been receiving a considerable donation of furniture from the ANZ Bank.

This was arranged by the contract manager for Allied Pickfords. As at 24 February six truckloads of

furniture have been delivered to the North Shore campus.

One issue identified as part of decanting and migration is lack of storage space across the

organisation. This is mainly evident in forward refurbishment projects. There are regular requests to

store items for services as a result of refurbishment resulting in less space available. Options are

currently being explored how this issue can be resolved

Fixtures Fittings and Equipment (FF&E) Signage

Procurement – 90% is now completed for satellite renal unit.

FF&E costings are within the budget.

Logistic planning is underway for Podium project.


Specific deliverables/actions to deliver improved performance will consider: On Target

Laboratory testing review and cost savings �

Pharmaceutical cost savings �

Development of the Allied Health workforce strategy �

Implement Fleet Management policy for fleet vehicles completed

Development of business cases for in-sourcing services (e.g. orderlies) completed

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Financial Result


The overall result for Hospital Operations is $535k unfavourable in the month, and $1.141M

unfavourable YTD

Revenue ($272k favourable YTD)

Car Park revenue is $277k favourable YTD reflecting the high number of patients and visitors as well

as the change in Tariffs from Jul-13. Asian Health unbudgeted income for CALD resources is $151k

favourable YTD, off set by unbudgeted other direct costs. Recharge to Inpatient services for

Outpatient pharmacy dispensing is $226k unfavourable YTD. This is due to changes in the

Community Pharmaceutical Schedule that has meant a reduction in the value recharged to Inpatient

services. Income from Auckland DHB for expenses incurred in joint Pacific Support service is $229k

favourable YTD.

Expenditure ($1,473k unfavourable YTD)

Personnel costs ($1,039k favourable YTD)

Nursing costs are $22k unfavourable YTD being Blood Transfusion Nurse in Laboratories offset by

budget in outsourced cost to NZ Blood. Support staff costs are $984k favourable YTD. This is

primarily due to the contracted FTE vacancy in Clinical Support - Cleaning and Orderly Services being

covered by agency casual staff. Management and Admin staff costs are $175k favourable YTD with

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vacancies to budget in Clinical Records and Clinical Transcription being offset by casual agency staff

in outsourced costs.

Clinical Engineering service has now been brought in-house with personnel costs being $246k

unfavourable YTD. This is offset by savings in Clinical Supplies where the budget for paying ADHB to

provide the service sits.

Other Direct costs ($2,512k unfavourable YTD)

Outsourced personnel costs for casual cleaning and orderly staff are $1,692k unfavourable YTD and

costs for casual admin staff are $425k unfavourable YTD. Asian Health unbudgeted expenses for

CALD resources are $143k unfavourable YTD off set by unbudgeted revenue. Activity related

variances in clinical supplies for Inpatient Pharmacy are $661k unfavourable YTD: Laboratories

including blood products are $231k unfavourable YTD and Outpatient Pharmacy is $50k

unfavourable YTD.

External storage costs for clinical records are $127k unfavourable YTD. Business Transformation plan

to develop records storage at NSH is progressing but savings will only materialise when we are no

longer retrieving from the external storage facility. Clinical Engineering service is now in-house,

resulting in savings in Clinical Supplies where the budget associated with paying ADHB for the service

is $308k favourable YTD.

Summary and Forecast Full Year:

The overall financial position for Hospital Operations is $1.1M unfavourable YTD and forecast to be

$2.0M unfavourable at year end. This is primarily due to activity related Clinical Supplies costs in

Pharmacy and Laboratories which are $942k unfavourable YTD, forecast to be $1,158k unfavourable

at year end. Also unfavourable due to savings plan initiatives embedded in Hospital Operations that

are either not materialising or savings show in other services being $341k unfavourable YTD and

$1,045k unfavourable at year end. These are being partly offset by favourable revenue from car park

activity which is $277k favourable YTD.

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Elective Surgical Centre

Service Overview

This new division provides elective surgical services to our community, working alongside the

Surgical & Ambulatory and Women & Child Health Services. It provides general surgery, orthopaedic

surgery, gynaecology and urology. It has its own outpatient clinic, operating theatres, CSSD and a

post-operative ward. The Director of the service is Dr John Cullen and it is managed by Mark

Watson.

Service Delivery Points of Interest for February:

• Volumes down in January but increased significantly in February

• Engaged with S&AS to move elective sessions over from NSH to vacant ESC theatre space

• Implementation of revised Booking and Scheduling process

• Commenced anaesthetic triage training for ESC Peri-operative Nurse Coordinators

• Internal operational processes working well within ESC

• Sharp increase in late finishes for some ESC sessions

• Consolidation of overall ESC theatre schedule with new, fulltime consultants starting.

• Final building defects continue to be identified and fixed in the lead up to the defect liability

period ending

Elective Surgery Volumes

January volume was below expectation and volumes continue to be below expectation year to date

due to SMO leave and our inability to backfill the vacant sessions. February picked up significantly,

however, and we saw the second largest volumes go through the facility since it opened. The overall

volumes, against expected production plans, remain a concern and we have now implemented a

change to the existing process to ensure that patient availability, timely anaesthetic triage/clearance

and adequate booking of patients to lists are all improved to rectify the problem. These changes will

also be adopted within the S&AS booking and scheduling process in time. This change is being driven

by ESC and we are working in conjunction with S&AS to remedy the above issues as soon as possible.

Overall, we remain concerned about the under utilisation of the ESC that is resulting in a continued

under delivery of patient volumes, and this remains in contrast to the over delivery in the

NSH/Waitakere theatres.

By the 18th March there had been a total of 2,125 patients treated year to date. As the graph shows,

there was a drop in volumes over January.

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Session Utilisation/Start & Finish Times

During February the ratio of actual sessions undertaken against planned session schedule was 88%,

with the average length of stay continuing at two days. Of these sessions, the actual utilisation of the

time allotted was 86%. Of note, 13 of the theatre sessions out of a total of 57 overran greater than

30 minutes in theatre. We have contacted the relevant surgeons to determine the reasons for this.

We have worked closely with S&AS to enable further utilisation of ESC theatre and bed space over

the coming months and have agreed to work towards full use of all four theatres, five days a week,

from July 2014 onwards. With the recent arrival of a number of new SMOs the current four weekly

theatre schedules of booked and regular operating lists have now been consolidated, allowing for far

better planning of resources and better utilisation of sessions. We now have 126 half day sessions

booked for regular operating out of a potential 160 over a four weekly cycle. The plan in place is to

look at increasing this to at least 145 sessions by July 2014.

It is essential that we have the ability to back fill, with both surgeons and anaesthetists, sessions

vacated by leave or CME, by either full time SMOs or locums.

Pre-Operative Assessment and Booking & Scheduling of ESC patients

ESC has revised the current booking and scheduling process, in collaboration with S&AS, to allow

tighter control over the management of the triaging, anaesthetic assessment and management of

waitlisted patients identified for surgery at ESC by the surgeon at their First Specialist Appointment

(FSA).

This new process has now been implemented and the anaesthetic department has commenced the

training of the Peri-operative Coordinators to undertake initial triaging of patients. Timeframes have

been put in place to ensure all patients receive anaesthetic clearance within 6 weeks of the referral

received. This will then allow the patients to be booked for surgery, up to four weeks prior to the

operating date, allowing much greater time to prepare the patients for the day of surgery and

providing a greater pool of patients to ensure full utilisation of the sessions. The process will take a

number of weeks to fully bed down, but will work in well with the reduced waiting time for surgery

implementation from five months to four months, from July 2014.

Defect Liability Period

Final building defects continue to be identified and fixed in the lead up to the defect liability period

ending at the end of May 2014. There are no major issues that have been identified at this stage that

causes us any concern.

Summary

Despite ongoing concerns over actual vs. budgeted volumes at ESC, assurances can be given that the

operational aspects of the facility are working very well and we have an outstanding team in place,

who work very hard to ensure that the hospital functions as efficiently as possible. Judging by the

feedback from our patients and SMOs, the consensus is that we are achieving a high level of

efficiency and productivity in the way we operate and this has not compromised the high quality of

the service in any way.

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Scorecard

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Deliverable /Action

Implement shorter journey and productivity models of care in ESC by 30 June 2014 � Implement remuneration package in ESC by 30 June 2014 � Implement PIPMS (Peri-operative Information Process Management System) system in

ESC by 30 June 2014

�

Ensure viable elective services units within ESC during 2013/14 � Primary Care access and streamline referral process pathways to the Elective Surgery

Centre (orthopaedics) in place by 31 December 2013

�

Implementation of new model of care for elective services delivery at the new surgery

centre

�


Key achievements for month:

• Implemented the new booking and scheduling process, led by ESC team

• Identified and rectified most defects prior to the defect liability period closing

• Created electronic access to key anaesthetic triage information, to assist

anaesthetists in a more timely assessment of their ESC patients

• Completed the new stock management process (Oracle Managed Inventory)

• Commenced the new registrar training programme with a general surgical session for

Lap Choles and basic suturing techniques

Areas off track for month and remedial plans:

• The overall anaesthetic assessing process needs to be finalised along with

anaesthetic/surgeon team – On-going discussions with the anaesthetic department

and S&AS

KEY ISSUES/INITIATIVES IDENTIFIED IN COMING MONTHS

Booking & Scheduling

The newly revised booking and scheduling process is now underway and we are working directly

with the managers of the Booking Clerks to ensure that it will allow ESC staff to have direct control

over the anaesthetic triage and pre-assessment of its patients, along with full overview of what is

being booked onto the operating lists, in sufficient time to allow for changes to be made. This is

progressing very well at the moment. ESC has now put on additional Pre-Anaesthetic Clinic (PAC)

sessions, using the spare space on the ward, to help cater for the increased demand.

Anaesthetic Teams/Triage and Pre-Assessment

There are now two lead anaesthetists for ESC whose role is to help develop rosters to improve

compliance to the surgeon/anaesthetist team combination, and to continue to develop the

anaesthetic pre-assessment process. As a result we expect to now see further improvements in the

team combination compliance and pre-assessment processes in upcoming months.

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Financial Results


Revenue

The MoH revenue variance YTD is $3.8M unfavourable, due to YTD elective wies volumes at 72% of

plan. Some YTD revenue associated with ACC and acute arranged cases has now been recognised in

ESC and total revenue is at 76% of budget, including these items. On a discharge basis relative to

planned cases, February is the best month since commencement at 88% of planned discharges, with

YTD discharges now at 74% of plan. YTD Average case weight per patient is marginally lower than

budget (1.48 v 1.52 or 97%).

Expenditure

Nursing: ($201k favourable YTD)

Nursing is holding 6 fte vacancies, whilst it is operating below planned levels. This has resulted in a

$201k favourable variance (plus a further $25k saving in bureau costs). However this is still at 92% of

budget as opposed to revenue at 76%.

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Admin staff: ($44k unfavourable YTD)

One senior nurse is classified as a manager compared to budget and this is the reason for the $44k

unfavourable variance.

Outsourced services: ($921k favourable YTD)

These expenses are primarily the Package of Care costs for surgeons and the Anaesthesia costs

charged by S&AS at close to budget levels. Surgeon Package of Care costs are $800k favourable (74%

of budget); and anaesthesia costs are $163k favourable (91% of budget). Overall this cost is at 80%

of budget, compared to revenue at 76% of budget.

Clinical supplies: ($388k favourable YTD)

Expenditure is $388k favourable at about 90% of budget compared to revenue at 76%. These costs

are generally variable except for depreciation of clinical equipment. After adjusting for depreciation

and reduced volumes, the YTD variance is approximately $500k unfavourable – primarily in

treatment disposable and diagnostic supply costs. With no history in ESC it is difficult to determine if

the budget is low or whether there are operational drivers to this outcome.

Infrastructure: ($283k favourable YTD)

Approximately $24k per month ($192k YTD) of infrastructure costs (software/electricity/water) are

not being charged to the ESC. Additionally a stock adjustment credit of $67k is reflected in this

result.

Summary

The February monthly result is $89k unfavourable and $2,032k unfavourable YTD. The month result

is the best to date, although it does pick up a net $160k of prior month revenue from ACC and acute

arranged cases, less some other un-accrued expenditure. The YTD position is primarily driven by

theatre utilisation and the resulting lower revenue, due to a variety of operational issues.

Expenditures are being held as much as is practical, however the key driver to improved results is

improved numbers of patients going through the facility. It is forecast that the current YTD position

will improve over the fourth quarter, which is assumed at 90% of planned revenue compared to YTD

76%, although the team will be focused on trying to deliver a higher level than that.

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Provider Arm Support Services

Corporate Services: Include offices of the Chief Executive Officer/Chief Financial Officer/Chief

Medical Officer/Director of Nursing/Director of Allied Health, Corporate Finance, Operational

Finance, Information Systems and Management, Facilities and Development, Quality, HR and Awhina

and Maori Services. It also includes outsourced healthAlliance services, HBL, Other affiliation costs

and financing costs. Robert Paine has overall financial responsibility for the Corporate Group.

During the current financial year, the management of Hospital Operations has been moved to

Surgical and Ambulatory Services, but in this month’s reporting the financial and scorecard data is

still shown as part of Provider Arm Support Services (financial data is also included in a separate

table in the Hospital Operations section).

Scorecard

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STRATEGIC INITIATIVES

Specific deliverables/actions to deliver improved performance will consider: On Target

Inventory management for clinical and non-clinical supplies �

Infrastructure costs/contracts and energy efficiency reviews and savings �

Commencement of new mental health facility He Puna Waiora, to replace Taharoto

Unit �

Mason Clinic remedial work �

Transfer of renal services: Phase II �

* include a �� or a ��


• Work is progressing on the new facility He Puna Waiora with the next official event being

the tree planting ceremony on 26th of March 2014 by the local Member of Parliament.

• Weekly communication is occurring directly with Carmel College facility staff and bi- monthly

meetings between the General Manager Mental Health, project director and Carmel College

principal.

• Two options are being worked through for the new link between He Puna Waiora and the

renal centre. A recommendation will go to the project steering group in April 2014 and then

onto the CEO for approval.

• Work is progressing on the project implementation plan and the introduction of new

processes and procedures by the time the new facility is completed.

• Mason Clinic – Maui. The design of the building is able to be generally accommodated on

the leased land. Waitemata DHB are now responsible for the removal of the cabbage trees,

the resource consent is expected to be lodged in March with the remaining consent to be

lodged shortly thereafter. Unitec requested Waitemata provide alternative dog training

areas however this is outside of the leased area. Access to the Oakley Creek Group across

the land will be diverted based on consultations undertaken.

• Renal Community Building construction continues on programme with practical completion

due in April 2014 and the unit opening in May 2014. Hawkins Construction has been granted

an extension of time, however the programme has been adjusted to accommodate this and

we remain on track.

• The inventory management project is ready for pilot implementation at Emergency Dept at

North Shore Hospital and one Ward at either North Shore or Waitakere Hospital. This pilot

project will include rationalisation of all supplies made to each pilot sites with focus on

buying all supplies from a list of catalogued products from approved vendors and prices.

Based on the work so far it has been established that each area in hospital has different

ways of ordering and stocking clinical and non-clinical supplies. This pilot project is designed

to be implemented in partnership with Health Alliance. A steering group has been formed to

provide leadership to this project with membership of CFO, GM’s, Director of Nursing and

Group Manager Finance & Planning.

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CORPORATE SERVICES GROUP HIGHLIGHTS / ISSUES

Health Information Group

The electronic Ward Whiteboard (eWW) roll-out starts in April 2014 with some exciting new

functionality including Allied Health referring, booked procedures and pharmacy dispensing. Medical

and Surgical wards at both hospitals are expected to have ward whiteboards by the end of June

2014.

A cancer coordination information system is being developed to track key points in the cancer

pathway. Health Information Group is using an existing application, Soprano Workflow Engine, a

system already in use by Renal Medicine and community services.

A report has been developed to identify patients with diabetes who have just been admitted to

hospital. The report looks at a range of sources to identify likely diabetes diagnoses; clinical coding

of past admissions, Diabetes clinic appointments and retinal screening. This report shows the

patients and their last HBA1C result. The report will help the Diabetes Service to improve clinical

management of patients.

The National Orthopaedic Enhanced Recovery After Surgery (ERAS) Collaboration is underway to

improve the pathway for Hip and Knee Replacement and Neck of Femur Fracture patients. The

Health Intelligence Team has worked with the Project Manager to submit weekly reports to the

national group.

Paediatrics at WDHB is the first service to go live with eReferrals Phase 2 (featuring electronic

triaging) on Monday 17th March. As of this date, all eReferrals for Paediatric Medicine and

Paediatric Cardiology will be electronically triaged by Waitemata DHB clinicians and messages

related to the triage process will be sent back to the GP. The next service to go live will be

Cardiology, planned for the end of April 2014.

The Clinical Records, Coding and Transcription services are maintaining local and national service

levels and targets. This is being achieved under the pressure of continuing higher than previous

year’s volumes of work for all services.

Facilities & Development

Highlights/Issues

• Testing for legionella continues at NSH, WTH, Mason and Wilson Home. All testing to date has

failed to detect any incident of the disease.

• Minor capital projects relating to improved environmental workplaces continue to be processed

with the work completed in a timely manner, these projects include air conditioning, new

carpet and painting at NSH and WTH.

• Negotiations have concluded for the lease of premises at Hibiscus Coast. A cash incentive of

$275,000 from the landlord has been paid. Minor upgrades are anticipated to better utilise the

facility.

• 2 Lake Pupuke Drive is deemed a leaky building. The building is leased and accommodates the

Breast Screening service. The landlord has completed some critical remedial works in the last

quarter of 2013. The Service has advised they can agree to remain in the premises for a further

3 years only, during which time the Landlord will continue to remediate the building.

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• The ground lease at Hoani Whititi School for a concrete pad to house a transportable dental

unit remains outstanding. We are providing assistance to the School to enable this matter to

be concluded quickly.

• In December 2013, we were alerted to further leaking in the Community Health Building. The

building has been known to leak from 1995 on a sporadic basis. Various rooms were vacated.

Independent air tests undertaken found some rooms had high levels of bacteria and spores. All

rooms vacated have been cleaned and fumigated by specialist cleaners. Many of these leaks

originate from the roof and approval was granted in November to replace the roof. The roof

replacement is due to commence in March once Building Consent is received. Thereafter

further condition assessments can be carried out to assess any other leaks.

Major Capital Projects

• NSH KMU remedial works concluded in December 2013, the ward remained mostly operational

during the project works. Minor defects are being completed by the Contractor.

• Ward 8 refurbishment project was placed on hold by the CEO pending a full review of

Christchurch designs and philosophy. Workshops, User Group meetings including listening

events have been taking place in January to enable guiding principles to be established.

• Renal Phase II Community facility was handed over from the Landlord in late November. The

clinical fit out is progressing, with handover for operational commissioning in April 2014.

• NSH Gym is now completed and operational. Options are being considered for a location at

WTH.

• WTH Low Load Chiller project works was completed in December with operational

commissioning undertaken during January 2014.

Other

• Vacancies remain for an operations engineer and a project manager. These vacancies are now

impacting on the efficiencies of the team.

• Approval was granted to recruit to the Sustainability role and this role has been filled in March

2014.

• The project management role has been placed on hold again pending Facilities and

Development collaboration with ADHB.

• The Personal Assistant role vacancy will be filled in April

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Financial Results


The overall result for Provider Support is $250k unfavourable for month and $653k favourable YTD

as at February 2014.

Revenue (Favourable $639k month, Favourable $2,878k YTD)

The favourable YTD position is largely due to $2.0M received in recognition of Pharmac savings, the

budget for which is included in other direct costs. Car Park revenue is favourable by $277k YTD

reflecting the higher number of patients / visitors and change in tariffs from Jul-13. In addition

Interest Receivable is favourable by $1.5M YTD while income from non-resident patients is

unfavourable by $644k YTD.

Expenditure (Unfavourable $889k month, Unfavourable $2,224k YTD)

Personnel Costs (Unfavourable $169k month, Unfavourable $893 YTD)

Budget savings not embedded in the services has a $3.6M YTD unfavourable variance in Provider

Support. These savings will be realised in the other Operating Groups. Support staff are favourable

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$1.5M YTD primarily due to the contracted FTE vacancy in Non-Clinical Support Cleaning and Orderly

Services being covered by agency casual staff. Management and Admin costs are favourable $1.4Mk

YTD with vacancies in Corporate Services and Hospital Operations partly offset by outsourced casual

staff.

Other Direct costs (Unfavourable $721k month, Unfavourable $1,332k YTD)

Budget savings not embedded in the services has a $2.7M YTD unfavourable variance in Other Direct

Costs. This is partly offset by $2.0M income received for Pharmac savings shown in Revenue.

Outsourced costs for casual staff in Hospital Operations are unfavourable by $2.1M YTD. Clinical

Supplies in Hospital Operations are unfavourable by $667k YTD being activity related costs in

Laboratories and Pharmacy. Non-clinical Supplies in Corporate Services are favourable by $2.3M YTD

primarily due to saving in interest and financing costs. Electricity costs are +$161k YTD being the

favourable pricing of new national contract.

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6.1 Clinical Leaders Report

Recommendation


Prepared by: Dr Andrew Brant (Chief Medical Officer), Dr Jocelyn Peach (Director of Nursing and Midwifery) and Phil

Barnes (Director of Allied Health and Acting GM for Hospital Operations)

Glossary

SMOs - Senior Medical Officers’

RMOs - Resident Medical Officers’

AT - Anaesthetic Technicians

RATs - Registered Health Professionals

PICC - Peripherally Inserted Central Catheters

CCDM - Care Capacity Demand Management, tools and programme supported by the Safe Staffing Unit

FAST - Quality Improvement method used by Waitemata DHB

Medical staff

Clinical Leadership

Michael Rodgers has been appointed Chief of Surgery for the service. An upper gastrointestinal and general

surgeon, Michael has been with Waitemata for the last ten years. He has previously held senior leadership

positions as Clinical Director General Surgery and President of the NZ Association of General Surgeons.

Michael established liver resection at this hospital and improved the journey to elective theatre through

the shorter journey pilot.

Richard Harman has been appointed Clinical Director General Surgery. Richard has worked as a consultant

surgeon with special interest in breast and endocrine surgery at Waitemata DHB since 1998. He has

previously held the role of Clinical Director of General Surgery from 2003 to 2006 and more recently has

provided leadership and direction to the Department of General Surgery as acting Clinical Director. Richard

has a wealth of experience and knowledge which includes development of comprehensive breast surgical

services at Waitemata DHB and being lead surgeon for Breast Screen Waitemata Northland.

Interviews are underway in April for the Head of Division roles, Medical for the Child, Woman and Family

directorate.

Senior Medical Officers (SMOs)

New SMO appointments: Simon Young in orthopaedics; Jeffrey Reddy and Melanie Speer in anaesthesia,

and Andrew Howie psychiatrist.

Resident Medical Officers (RMOs)

Members of the MCNZ Education Committee will visit on 17-18th July for an accreditation visit. The

purpose is to ensure the education, training, supervision and facilities available meets the medical council

standards. The Medical Education and Training Unit and Mr Pat Alley, Clinical Director of Medical Training,

will be leading the preparation for the visit.

The New Zealand Medical Council (NZMC) is implementing changes to doctor’s training and education that

will improve patient safety and the performance of doctors. The changes are being phased in over the next

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two years. In March 2014 the Medical Council released the first change which is the New Zealand

Curriculum Framework for Prevocational Medical Training (NZCF). A staged implementation of the NZCF

will commence in November 2014 for those entering PGY1. Interns, Prevocational Educational Supervisors

and others involved in prevocational training will be able to use the learning outcomes in the NZCF as a

guide for training and educational programmes. Full implementation cannot occur until clinical attachments

have been accredited, which is scheduled for November 2015. The changes will have a significant impact on

training of our junior doctors in the DHB, and in particular supervision requirements of the SMOs. We will

be working with council this year to ensure that we provide appropriate environment for the new

curriculum.

In April 2014 we will submit to the regional RMO process our intentions for new RMO positions for 2015.

This is currently being worked through the services

GP open day

We held the first GP open event on February 25 in the evening. GPs were shown around the North Shore

facilities, including Emergency department, cardiology, and Elective Surgery Centre. This was followed by a

general question and answer session. It enabled the DHB to outline recent developments, and discuss

interface and integration issues. The event was very well received and has led to further opening of

channels of communication with our primary care colleagues to interact with the DHB. Further events are

planned, the next being in Waitakere Hospital. Future events may be centred on service themes.

Allied Health, Technical and Scientific staff

Anaesthetic Technicians

The core workforce involved in anaesthesia comprises medical practitioners (Anaesthetists), Nurses and

Anaesthetic Technicians (AT) and there is considerable variation nationally and internationally in the scope

of practice of each of these groups and therefore the skill mix within any perioperative environment.

Anaesthetic Technicians have existed in New Zealand since the early 1970’s, anecdotally having evolved

from a group of theatre orderlies who expressed an interest in assisting anaesthetists during surgery.

Training programmes were developed in the late 70’s and the role became formalised with strong support

from the College of Anaesthetists. There is now at least one AT in every operating theatre at WDHB.

The Waitemata DHB AT Department has been led by Julie Bromley since 1997 and around that time the

newly opened ICU was run by Anaesthetists, with their AT assistants. Thus it was recognised that AT skills

were readily transferable to emergency departments and ICU and in consequence ATs are now part of the

emergency resuscitation team, attending all adult resuscitation, trauma and medical emergency calls 24/7.

ATs were also found to be useful in assisting ward staff with difficult cannulations and during the RMO

strike of 2009 were asked to provide a formal hospital-wide cannulation service. Coincidentally, the rate of

line sepsis decreased significantly at that time.

In 2012 ATs became registered health professionals (RATs!) under the Health Practitioners Competence

Assurance Act 2003. Immediately prior to this, ATs were asked by HWNZ to pilot a scheme for the insertion

of Peripherally Inserted Central Catheters (PICC lines) to free up SMO time. This trial was very successful

and the AT led service demonstrated quicker referral-to-insertion time, reduction in procedure time and

significantly reduced failure rate. Now 95% of all PICC lines (average 15 per week) at WDHB are inserted by

RATS. It should be noted that a significant proportion of the RAT workforce is trained overseas (generally

UK) where their role as Operating Department Practitioners has a much wider scope than that outlined

above for New Zealand practitioners and gives an indication of the underutilised skills and potential of this

particular technical workforce.

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Laboratory Service

The Clinical Director of the service, Dr Ross Henderson has resigned from this position due to clinical

haematology workload pressures. Whilst Ross will continue to contribute to leadership of the service and

may return to his original role at some point in the future there is a need to secure clinical pathologist

support, at least in the interim. Preliminary discussions have occurred with LabPlus (ADHB) around the

possibility of a collaborative approach to the problem and possibly a joint appointment between ADHB and

WDHB. These initial discussions were very positive and gave rise to a number of possible options that are

currently being explored by the laboratory management team.

Allied Health Therapies

The Nutrition and Dietetics team is now at full complement following the appointment of Teresa Stanbrook

to the Professional Leader role and the morale of the service has significantly improved.

The allied health clinical governance group comprising professional and clinical leaders and senior

managers continues to meet and is developing into a vibrant forum for debate and decision making.

Dental Therapy

The Director of Allied Health, in conjunction with the Professional Leader Dental Therapy and Allied Health

Leader (CWF) are in the process of organising an auditor training course for up to 20 Dental Therapists and

service leaders to enable them to establish a formal and systematic peer review programme for the

Auckland Regional Dental Service.

Continuing Professional Development Fund

The CEO’s newly established professional development and training fund has been particularly well

received by the allied health, scientific and technical staffs as the majority of these professions have no

formal allocation of funds for continuing education and professional development. Processes are being

developed to ensure transparent and equitable distribution of the money within and between services and

the relevant professional groups.

Nursing and Midwifery

Activity using key priorities: Nursing and Midwifery

Provide a positive experience of care

Feedback to the senior nurses and midwives is planned in the next week from the ‘In Your Shoes’ event so

that learning can be applied to the next phase of patient experience work.

Deliver high quality care and measure impact

Quality programme

There has been good staff engagement in some key projects to improve the quality of professional care:

• A recent Nutrition and Hydration workshop involved 35 staff consisting of nurses, allied health staff

and the disability advisor, working very constructively together to identify the barriers to best

practice and key priorities to make improvements. Outstanding achievement was the work of the

registered nurse nutrition champion on Ward 7 and the Charge Nurse Manager who urgently

introduced ‘Protected Mealtimes’ with positive effect. This high priority work is ongoing.

• Pain Management Awareness FAST project, led by Shirley Ross, Head of Division Nursing is

addressing an important issue for patients in the inpatient setting.

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• Pressure Injury Prevent FAST project – led by Jeanette Bell, new Essentials of Care project assistant

working with Jenny Parr, Associate Director of Nursing.

• End of Life practice improvement – led by Tania Chalton which is engaging a number of champions

and is showing improvement.

The focus on quality improvement and safety is evident in all divisions. Each Head of Division for Nursing

and Midwifery is leading work on: documentation, medication safety, professional presentation and

essentials of care. The range of audit results shows improvement and increasing consistency in auditing

practices.

Build and strengthen professional leadership

• Charge Nurse Development Part 1 and Part 2

As reported previously, Part 1 of the Charge Nurse Managers development programme work commenced

with a two day workshop in March and the Part 2 cohort will commence in September 2014. The role of

Charge Nurse/Midwife Manager is important in an organisation as they set the culture at ward/unit level

which influences the direct care and the patient experience.

• Other senior nurse development

Leadership development of other senior nurse and midwife roles is underway as well.

Ensure we have the right staff, with the right skills in the right place

• Workforce planning Trendcare and CCDM [Care Capacity Demand Management]

Work continues to ensure we have a clear understanding of the acuity needs of patients and that there is

appropriate resource to meet these patients needs. This issue is becoming increasingly important to the

staff and their unions. We are engaging staff with the information that can be extracted from the

databases so that they can understand the importance of accuracy and consistency.

Support positive staff experience

Work continues to find ways to address staff experience of ‘everyone matters’. Ideas arose from ‘in your

shoes’. Plans to increase visibility, delivery on what they say is important to them in order to deliver quality

patient experience is underway.

Activity using key priorities: Emergency Systems Planning

The DHB annual exercise is planned for the beginning of April with good interagency emergency services

participation. There is increasing interest from residential aged care and primary care.

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6.2 Human Resources

Recommendation:


Prepared by: Sam Bartrum (Director, Human Resources)

Executive Summary This report identifies some key areas that are occurring in Human Resources for the

month of March 2014.

Occupational Health & Safety WDHB Influenza Campaign

The 2014 Influenza campaign programme is underway with considerably more vaccinators

than last year. The target is to exceed 55% (2013) and the campaign’s aim is to access more

areas more often. The timetable is available on the OH&S website and there will be roving

as well as static vaccinators. There will be a communication programme to update staff

throughout the campaign.

Recruitment

No. Hires

(All permanent, fixed term, casual roles)

-

50

100

150

200

Feb-

13

Mar-1

3

Apr-13

May-

13

Jun-1

3

Jul-1

3

Aug-13

Sep-

13

Oct-1

3

Nov-13

Dec-1

3

Jan-1

4

Feb-

14

Cost per Hire ($)

(this includes advertising costs, relocation costs and

Monthly Recruitment Centre Running Costs)

-

200

400

600

800

1,000

Feb-

13

Mar-1

3

Apr-13

May-

13

Jun-1

3

Jul-1

3

Aug-13

Sep-

13

Oct-1

3

Nov-13

Dec-1

3

Jan-1

4

Feb-

14

Cost per Hire Cost per Hire Target ($)

Time to Hire (days)

(From candidate application to hire)

-

20

40

60

80

100

Feb-

13

Mar-1

3

Apr-13

May-

13

Jun-1

3

Jul-1

3

Aug-13

Sep-

13

Oct-1

3

Nov-13

Dec-1

3

Jan-1

4

Feb-

14

Time to Hire (days) Time to hire Target (days)

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KiwiHealth Jobs

Number of Jobs advertised by month and organisation

0

10

20

30

40

50

60

70

80

Northla

nd

Auckla

nd

Waite

mat

a

Counties M

anakau

Waik

ato

Bay of P

lenty

Tairaw

hiti

Taranak

i

Lake

s

Whanga

nui

Hawke

s Bay

Mid

Centra

l

Wai

rara

pa

Capita

l and C

oast

Hutt Valle

y

Nelson M

albro

ugh

Cante

rbury

South

Cante

rbury

West

Coas

t

South

ern

NZ Blo

od

Jan-14

Feb-14

At a glance – February 2014

Total number of visits: 38,388

Visits from:

UK

Australia

USA

Canada

Ireland

2732

1923

1414

566

291

Number of jobs posted

Clinical jobs

Non-clinical jobs

366

96

Key Highlights

• Total visits to the site remain steady; February had close to 40,000 visits to KHJ

which was consistent with January figures.

• There was an increase in traffic from Ireland and Canada – up 29% and 19%

respectively.

• Subscribers registered for job alerts continues to rise; 8,790 at the end of

February, up from 8,399 in January.

• The top 5 DHB referrals in February were Waitemata, Mid Central, Nelson

Marlborough, Waikato and South Canterbury DHBs.

Workforce Development

Values Implementation

The Best Care for Everyone programme continues to be a key focus for the workforce team.

A set of service standards and behaviours aligned to the values are completed and will be

launched as part of an organisational communication strategy in April. Phase 2 activity has

begun with a focus on values based recruitment workshops, In Your Shoes sessions for

SMOs, In your Shoes sessions for Maori, Asian and Pacific patient/client groups, leading to

the values, appraisal documentation and measurement of the patient and staff engagement.

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There is a strongly positive organisational response to the values programme and the rigour

of the processes and outputs is ensuring sustainable development and cultural change.

Allied Health Assistants Qualification

A successful graduation ceremony occurred for the Allied Health Therapy Assistants who

have completed the Level 3 National Certificate NZQA qualification. As Waitemata is the first

DHB to have a group complete the qualification, a representative group is facilitating a

workshop at the Allied Health Scientific and Technical Conference to be held late March

2014 at Health Waikato. The purpose is to share our journey and work with others both

regionally and nationally to grow this workforce.

Further work is occurring internally to work towards the enhanced use of the newly qualified

therapy assistants as part of the MDT.

Scholarship Programme

There was an award ceremony on 25th February for the 12 Māori students on the

Scholarship programme, and their Whānau. The purpose was to strengthen WDHB’s

connection with the students and their Whānau, whilst facilitating networking and

whanaungatanga among the students, Ngāti Whātua iwi members and the Waitemata DHB

staff who attended: He Kamaka Waiora Maori Health Gain team across Funding and

Planning and the provider arm, Director of HR, Workforce Development Manager, Pacific

Workforce Development Consultant, and Service Managers who interviewed the students on

the panels.

Outcomes included two students engaged with Dr Helen Wihongi around research, one

student engaged with Dr Sue Crengle around mentoring, one student engaged with John

Paterson and Sam Bartrum around employment opportunities as a new grad Podiatrist, and

all students in attendance received information about the WDHB My Career Path

programme.

Further work is being done to recruit a final three Physio and three Med Lab students for the

2014 Scholarship programme.

Māori Recruitment: Partnership with Ngāti Whātua o Ōrakei

Ngāti Whātua o Ōrākei have undergone some internal changes to the delivery of their

programmes. This has resulted in a shift of focus for them, and they now have a new team

named Whai Poutama who aim to facilitate employment for tertiary students of Ngāti

Whātua descent across all sectors.

Where links exist, Whai Poutama will register their students with the national Māori health

workforce development programme Kia Ora Hauora, and if eligible, support them to apply

for the Waitemata DHB Health Scholarship or the Whakatupu Hauora Scholarship.

Both the Kia Ora Hauora programme and the Scholarship programmes work with Waitemata

DHB to provide a facilitated employment process for students upon completion of their

qualification.

Pacific Health Science Academy & Mentoring Programme

We are actively working on the implementation plan and related immediate activities.

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A recruitment process for the role of Programme Manager – Health Science Academies is

underway. This role will be based at WDHB and will be responsible for the implementation

and delivery of the Health Science Academies.

The first regional governance meeting has just been held with good engagement from all

parties. This group will meet monthly during the initial set up phase and then quarterly after

that. The role of this group is to ensure contract targets are met and to facilitate action

within DHBs if barriers and issues are identified.

Internal Communications

Publications

The internal communications team published the following over the past two months:

• Healthlines – monthly 12 page staff magazine available online with 1200 printed copies

• Primary Care News – monthly magazine for Auckland GPs with contributions from

Waitemata, Auckland and Counties Manukau DHBs

• Waitemata Weekly – a weekly e-newsletter for all staff

• A Note from the CEO – a fortnightly message from the CEO to all staff

• Weekly health targets update – weekly update and commentary on health targets to all

staff

• Maintenance of StaffNet (WDHB’s intranet site), Awhina website, Waitemata DHB

external website and Waitemata DHB pages on Health Point

• A range of booklets and leaflets

Project/campaign work

The internal communications team provided communications advice and support to the

following projects/campaign in March:

• Community dialysis facility in Apollo Drive

• Waitakere Hospital maternity unit – planning for 50th anniversary celebrations [June

2014]

• ADCU [Assessment Diagnostic Cardiology Unit] name change communications

• CWF communications planning re changes to child health service

• ACP [advanced care planning] open day communications

• IPANZ public sector excellence awards – video / poster support

• Corporate orientation presentation update

• Values campaign

• Chapel project

• healthAlliance windows 7 rollout project

• MRI project including media activity re arrival of Philips magnet [28 March]

• He Puna Waiora [new mental health facility on Shakespeare Rd] tree planting ceremony

with media and local MP in attendance [26 March]

• 2014 flu campaign

• Establish research project with North Shore police intelligence unit and NSH ED

• Sustainability comms

• New fresh food options in NSH staff cafeteria

• Proofing various department newsletters

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Other support

March Health Heroes celebration.

Awhina Education & Learning

Education and Learning Governance at Waitemata DHB

The recently established Waitemata DHB Education and Learning Committee meets every six

weeks. Two meetings (5 February and 20 March) have been held to date. The committee is

chaired by Dr Jonathan Christiansen. It provides a central connection for education and

learning across the DHB. It aims to link learning and development with the provision of

clinical care in the services and provide advice and guidance to the senior management team

to support their decision-making.

The programme of work for the first six months is:

1. Complete establishment of the Education and Learning Committee

• Invite a primary care representative to join the core committee

• Establish a virtual consultative group to enable a broad group of staff to participate

in education and learning issues as they arise

• Get sign-off on the Terms of Reference.

2. Establish key sub-committees

• Professional development fund committee. This committee has an annual budget of

$250k. The first task for the committee is to establish criteria and an application

process for staff to apply to access funding

• Internal conferences, seminars and speaker series committee

• Education, Research, Conference and Learning Centre user group – working in

conjunction with Dr John Cullen

• Mandatory training committee.

3. Conduct stock-takes to establish a baseline of information

• The first stock-take the committee will conduct will focus on parties external to the

DHB who influence education and learning and service provided within WDHB. The

stock-take will look at the extent and impact of these external requirements.

Resident Doctors

Medical Council NZ (MCNZ) Accreditation Visit

The MCNZ will visit Waitemata DHB on 17-18 July for the accreditation site visit. This has

been reported on previously to HAC. Preparation for the visit is on track.

Resident doctor protected teaching time programme

Under their union agreement, resident doctors have two hours protected teaching time

each week. Waitemata DHB schedules this each Thursday from 12.30-2.30pm. Paging

behaviour was recognised as one of the key barriers to our DHB meeting this protected

teaching time requirement. There was a tendency for resident doctors to arrive and sign in

for the session and then respond to their pagers/leave to attend to ‘urgent calls’ during the

session. Given the regularity of this behaviour we recognized the need to address it. Two

things occurred as a result (i) leaving the sessions to answer pager calls has significantly

reduced and (ii) the frequency of calls has diminished. Resident doctors are now better at

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filtering urgent v non-urgent calls and actively managing this for themselves. Some of this

change in behaviour has been made possible by the new SmartPage system.

The resident doctor programme is a year-long programme designed to meet the MCNZ

curriculum requirements. It is structured into five teaching blocks underpinned by four

crucial elements: quality, clinical skills, inter-professional education and collaborative

practice, and safe prescribing. The programme is facilitated by in-house specialists and is as

follows:

Block Teaching topics e-Learning modules

Orientation

Week one

DHB values and welcome

Occupational health and safety

Cannulation

Medication chart

Infection, prevention and control

Catheterization

Fire Safety

Occupational H&S

Infection, Prevention &

Control

Informed Consent

Adult Medication Chart

Medication History

Survival Series

13 weeks

Supports early

expectations of

the role

Ward calls and handovers

Certifying death

Fluid management

Medication safety

Surgical do’s & don’ts

Pain relief

ABC of chest x-rays & working with the

radiology dept

Acute chest pain, acute shortness of

breath, oxygen therapy

Palliative care

Difficult conversations

Sepsis and antibiotic choice

Prescribing for the elderly

Peri-operative work up – from consent

to assessment

Electronic discharge summaries

Tramadol and Oxycodone

Medications in the Elderly

Gentamycin

Metroprolol

Consolidation

Part 1

13 weeks

Blends theory

and practice

Acute urology (skills, prostate exams &

review of catheterization)

LA, suturing, haemostasis & dressings

Delirium, depression & dementia

(cognitive testing)

Diabetes management (blood glucose

testing)

Gastrointestinal conditions (university

challenge style Q&A)

Arterial blood gases (punctures)

GI bleeding

Lumbar punctures

Chest drains (drain insertion &

removal)

Stroke (MDT management of stroke

patients)

Insulin

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Toxicology, drug overdose and

anaphylaxis

Quality, learning from our mistakes &

ACC

Consolidation

Part 2

14 weeks

Case

presentations &

reflective practice on

clinical scenarios

Keys to presenting & giving feedback

Nephrology

Respiratory

Gynecological

Infectious diseases

Nutrition & metabolism

Musculoskeletal

Haemopoietic

Psychiatric/drug and alcohol

Neurological

Domestic violence

Endocrine

ENT otorhinolaryngology

Circulatory

Dermatological

[the Healthcare Challenge

Team challenge for

interdisciplinary teams

occurs during this teaching

block]

Transition to

post-grad, year 2

8 weeks

Career direction and planning & next

steps

Preparing your CV and interview

preparation

Values – your career and the values

you hold

Moving and Handling

1:1 teaching and coaching skills

Medication safety

Skills for audit & research – developing

a research question

Communication/health literacy

Preparation for working in ICU and ED

Feedback and end of year round-up &

certification ceremony

We are currently midway through the ‘Consolidation – Part 1’ programme and detailed

planning is underway for ‘Consolidation – Part 2.’

The MCNZ has recently published an updated version of the curriculum for resident doctors

and a review of our programme against those requirements shows no adjustments to our

programme are required.

Charge Nurse Managers – leader development programme

The Leading Quality Care – leader development programme for CNMs is a seven day

programme delivered over 8 months. It’s a new programme that is being piloted for a group

of 13 charge nurse managers from Medical and Health of Older People Service and from

Surgical and Ambulatory Services. The first two days ran at the beginning of March.

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Following the first two days, charge nurse managers were asked to do two things: carry out

ward observations in their own wards/within their own teams; and form learning sets for the

duration of the programme. Members of the Learning and Development team have

facilitated the first sessions of each learning set to help them get established.

It’s too early for there to be significant shift in terms of leader behaviour but observations to

date are encouraging. CNM’s report that they are observing what’s happening in their

wards with new eyes, some of them are naming and challenging behaviour that

compromises quality care and others are using their learning about the Myers Briggs

personality profile to support and enhance their communication with others.

The programme has been designed in two parts. Part 1 focuses on strategies for leader

readiness and part 2 focuses on strategies for leading quality care.

e-Learning

Our Learning Technologies team has continued to work closely with subject matter experts

across our DHB to design and develop e-Learning courses for staff. See below for a

complete list of courses:

CODE: (*) edited; (+) redesigned; (-) not developed by Awhina; Blue text – new course in

development

Category Course

General 1. Nicotine Replacement Therapy

2. Smoking Cessation

3. Healthy Eating, Healthy Weight

Clinical Procedural

Skills

4. Thrombolysis

5. Central Venous Catheters (*)

Enteral Nutrition 6. Inter-Disciplinary Team(*)

7. Dysphagia and SLT

8. Medications

9. Nutritional assessment

10. Tube placement & Potential Issues with enteral feeding

11. Treatment

12. Monitoring

13. Discharge

14. Cultural & Ethical Safety(*)

Safe Use of Medicines 15. The Adult Medication Chart

16. Medication History

17. Tramadol

18. Gentamicin for Adults

19. Insulin

20. Heart Failure Medications

21. Medications for Older Adults

22. Buscopan

23. Metroprolol

24. Oxycodone

25. Gentamicin for neonates and paediatrics

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Category Course

26. Pharmacological management of

pain (+)

27. 3D’s: Dementia, Delirium and dehydration

Diversity 28. Disability Awareness

29. CALD programme (-)

30. Sharing information with Family/Whanau

Patient Safety 31. Informed Consent 2014(*)

32. SOAP - Clinical Documentation Notes

33. Good Clinical Research Practice

34. MHSOP

35. SCBU

Annual Updates 36. Level 3 CPR(*)

37. Fire Training (+)

38. Occupational Health and Safety Services

39. Privacy of Health Information

40. Infection Prevention & Control

Clinical (+)

41. Infection Prevention & Control non-clinical

42. ACLS Recertification Theory Test

43. Nursing Code of Conduct

44. Blood Culture Safety

Products 45. AMS Leader Training

46. Trendcare Pre-Testing

47. e-Prescribing

48. Stastrip Xpress

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7.1 Synthetic Cannabinoids

Recommendation


Prepared by: Susanna Galea (Clinical Director CADS)

Purpose of this report

To inform the WDHB Hospital Advisory Committee on the concern related to harm from the use of

synthetic cannabinoids and the approach being taken on this issue.

What are they?

Synthetic cannabinoids, also referred to as ‘synthetics’, are substances that mimic the effects of

cannabis, although with significantly greater potency and efficacy. They are marketed as legal

substitutes for cannabis, sold in our local shops often at close accessible proximity to hospitals and

other treatment settings. ‘Synthetics’ usually consist of a chemical agent sprayed onto dried plant

material which is smoked (and sometimes consumed as ‘tea’). Common names include: Apocalypse,

Outbreak, Tai High, and Giggle (also, Kronic, Spice and K2- which are now banned).

The concern

The emergence and proliferation of synthetic cannabinoids within the NZ market, and globally, is of

great concern. Very little is known about the safety profile of these substances, however it is clear

that they have numerous adverse side effects. The evidence that is available is mainly anecdotal

(reported on social media/internet sites by users), and via case studies reported in the literature.

Frequent adverse effects reported through case reports and calls to the National Poisons Centre in

New Zealand, include: dependence, psychosis, hallucinations, anxiety, agitation, tremors, seizures,

drowsiness, tachycardia, hypertension, chest pain, tachypnoea and vomiting. Other less frequent

adverse events include: respiratory depression, loss of consciousness, rhabdomyolysis, acute tubular

necrosis and renal failure. All these reported effects had been severe enough to require medical

attention. Stopping use of synthetics can trigger withdrawal symptoms that can last a number of

weeks.

Although little is known about the prevalence of use of such substances in the general New Zealand

population the ‘synthetics’ industry is extensive and profitable, suggesting use is not insignificant.

Presentations at emergency departments, mental health and addiction units suggest an upward

trend in usage overall (however over the past few months some downward trends have been

observed also).

The most recent report by the Illicit Drug Monitoring System (IDMS), shows increasing trends over

the past few years – see figure below. Although the IDMS interviews frequent drug users these data

show that there was a trend for increasing use of these substances during this time which reflects

increased availability. The emergency department in Dunedin reported that 79 out of 1702

attendances over a 6 month period (April to September 2013), involved synthetic cannabinoids. The

National Poisons Unit reported an increase in number of calls related to synthetics, from October

2013 to November 2013; followed by an apparent reduction from November 2013 to January 2014.

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Over the past two years CADS has experienced an increasing demand to address health needs

related to use of synthetic cannabinoids. Cannabinoid presentations tend to be complex and can

utilise more health care time than other presentations. Anecdotal evidence suggests that about 40%

of people presenting at CADS report use of synthetics. It is unclear how many of these have

‘synthetic use’ as their main presenting complaint, however CADS is looking at ways to collect this

data into the future. Some CADS services are able to provide more detailed information. Medical

detoxification services have assessed 4-5 people a month for the past 8 months requesting support

to withdraw from synthetic cannabis and a large percentage of these clients have been admitted to

the inpatient unit. The Youth Service ‘Altered High’ reports 2-3 new referrals a week that have

‘synthetics’ use as the reason for referral.

A cross sectional audit of the CADS Altered High Youth Service conducted in 2011 found that 42% of

clients had used ‘synthetics’ and that 32% of these users had experienced problems as a result of

use including mood difficulties (16%), family arguments and conflict (16%), school problems (14%),

addiction/dependence (11%) and criminal or violent behaviour (9%).

Legal status

In July 2013, the New Zealand Government introduced the Psychoactive Substances Act to regulate

the availability of psychoactive substances and protect the health, and minimize harm to individuals

using these substances. New Zealand is leading in this approach to regulate availability – no product

will legally go on the market before it is deemed as low-risk. As synthetic cannabinoids are classed as

psychoactive substances, and are not listed under the Misuse of Drugs Act, they will be considered

by the Psychoactive Substances Act.

The Act stipulates that a product will only be approved for use if it poses a low risk of harm to

individuals. Before a product is approved for use, the degree of harm will need to be assessed. The

onus to prove low-risk lies with the manufacturer. As an intermediary step in the implementation of

the act, a number of synthetic cannabinoids were granted interim approval under the Psychoactive

Substances Act and are sold in New Zealand by retailers (see -http://www.health.govt.nz/our-

work/regulation-health-and-disability-system/psychoactive-substances/interim-product-approvals

for a full list of approved for sale products e.g. AB-Fubinaca, PB-22-F, CP-55244). The MoH will

revoke these approvals and recall the products if it judges, from reports of adverse effects, that a

product poses more than a low risk of harm to the user.

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The MoH is encouraging clinicians to report adverse events to the Centre for Adverse Reaction

Monitoring (CARM). Reporting of adverse effects plays a crucial role in the recall of products from

the market. CADS currently is promoting reporting of adverse effects to CARM across its various

services.

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