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Auckland District Health Board

Quality Account 2012 / 2013



Contents 1.0 Foreword......................................................................... 2 2.0 Keeping our patients safe............................................. 11 3.0 Better quality care and patient experience.................. 25 4.0 Healthier communities................................................. 41 5.0 Creating better value for you........................................ 55 6.0 The best team to deliver quality................................... 67 7.0 Our future focus............................................................ 75 8.0 Quality improvement projects...................................... 88

ISSN 2350-2800 (Print) ISSN 2350-2819 (Online)


Foreword We are pleased to introduce the first Quality Account for Auckland District Health Board. The quality and safety of care continues to be our highest priority and this document provides a published record of our achievement against this commitment for our patients, the Auckland DHB population and our wider stakeholders.


Each year we will publish a Quality Account to provide a view of how we are delivering quality health care. Producing these accounts helps us to assess quality across all our services and encourages the process of continuous, evidencebased improvement. It also provides us with an opportunity to showcase our successes and highlight those areas where more work is required. We have committed to producing our Quality Account alongside our financial accounts in recognition of the value and status of both of these dimensions. What does quality mean at Auckland DHB? We define quality as the provision of care that is safe, effective and provides a positive patient experience. Safe and effective care is what’s expected of healthcare providers, but equally important is that latter point, the patient experience. We expect that every Auckland DHB patient and their family/whānau are treated with the utmost empathy, respect, courtesy and professionalism. Healthcare is a tough and demanding environment and sometimes in a busy working day it is possible to forget that our patients are someone’s family member or friend. We see people at a low point in their lives, when they are tired, frail and even afraid and we must do everything that we can to make it easier for them.

In this reporting year, we can report a number of quality healthcare highlights including: • Achieving the highest level of hand hygiene compliance in the country. • Being the first DHB in New Zealand to roll out an online mental health service ‘Big White Wall’ – the mental health equivalent of Facebook. • Being the first DHB to exceed the national target for cardiovascular screening, with 77 percent of our eligible Pacific population screened by May. • Improving our processes so that collectively patients spent 133,921 fewer hours in our emergency departments than previous years. • Meeting the target for falls assessment, assessing 91 percent of patients for falling risk. • Making significant strides on two other national health targets – immunisation and smoking cessation. At eight months of age, 90 percent of all children were fully immunised, five percent above the target. Likewise, we met the national target providing 95 percent of all patients seen in hospital with advice to quit.


Achieving quality outcomes means doing things differently in order to do them better. Our world has changed and we need to face the reality that we cannot meet the new challenges confronting us by continuing to do things as we have in the past. Like many healthcare providers we are facing serious challenges. Firstly, we need to better understand how our population wants to access health care and how they want to manage their own health. We all know more prevention and early intervention are important, but our community and primary services are limited and we are still doing things ‘to’ and ‘for’ people rather than supporting them to manage their own health. We are, however, excited that more of our service developments and improvements are now involving patients in their design. This year we have started to think about how we can offer a more self-directed care approach to health, supporting people to take greater control over their own health and wellbeing and helping them to maximise their quality of life.This approach is gathering momentum, both here and overseas, and is something we plan to focus on into the future.

Our second challenge is one faced by healthcare providers worldwide. Delivering health services in the way we do today is becoming increasingly unaffordable. Our costs are growing at around six percent while income is growing by about 1.5 percent. We need to confront the reality that our current model of health service delivery is too expensive and unsustainable, particularly in the face of the very challenging demographic changes that we are already seeing. If we can increasingly empower patients to manage their own health, we can make significant savings and improve our patients’ experience and in this way ensure that the system has the potential to be sustainable into the future.

Supporting the health of our population is something we do in partnership with a range of other agencies, some of whom are identified in this document. We are grateful to our partners in primary care because without them quality outcomes would be more difficult to achieve. We are seeing more collaboration across the region, and nationally, and while it is enabling change at a pace not seen previously, it must accelerate.

We have significant capability and we have the tools, but often not the capacity or an environment that empowers people to make change. However, we are pleased to report that this is changing as the initiatives featured in this document attest.

Dr Lester Levy, CNZM Chair Auckland District Health Board

Producing a document such as this Quality Account provides us with an opportunity to critically examine where we are in our pursuit of quality. In short we think Auckland DHB’s performance is good, but it could be better. Together with our community we can rise to the challenge to provide quality healthcare for our population in a cost effective way.

With the innovation and dedication of the people who work at the Auckland District Health Board, and those we work with in the community and private sector, we will continue to look for ways to embed quality in the services we provide and identify opportunities for improvement. We hope you enjoy learning more about your District Health Board’s quality journey and, like us, take pride in what the team at Auckland DHB has achieved.

Ailsa Claire, OBE Chief Executive Auckland District Health Board



Keeping our patients safe

A snapshot of our activity and performance

Assessed 91% of hospital patients for falling risk (up from <75%)

Classified pressure injuries as “never events” and had only one serious pressure injury since July 2012

Better quality care and patient experience Held 799 advance care planning conversations helping people to talk about end of life care

Improved processes so that patients spent 133,000 fewer hours waiting in our emergency departments1

Changed the way we treat patients requiring hip surgery, reducing the length of stay by more than a day

Improved our outpatient booking service so we can deliver elective surgery to outpatients at a time that’s convenient, first time (reduce cancellations) and on time

1 Note: this figure is for the calendar year 2012, not the financial year 1 July 2012–30 June 2013.

Achieved the highest level of hand hygiene compliance in the country

Exceeded 100 days without a central line-associated bloodstream (CLAB) infection in three of our intensive care units

Performed crucial checks on 99% of our patients on entering the operating theatre (checks on their identity and intended surgical procedure)



Healthier communities The first DHB to exceed the national cardiovascular target set by the Ministry of Health with 77% of our eligible Pacific population screened by May 2013 The first DHB and health organisation in New Zealand to roll out the Big White Wall, the mental health equivalent of Facebook for people aged 16-plus


Exceeded the national target for immunisation for children. At eight months of age, 90% of all children were fully immunised, up 5% on the national target

as ly

100% achievement of the national target to provide radiation or chemotherapy cancer treatment within four weeks Provided ‘brief advice to quit’ to 95% of all patients seen in hospital Provided home-based support to 3850 clients, of which 76% are aged 85 plus, helping us reach our goal of enabling older people to remain living in their homes

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Opened the last of 14 new community dental clinics and completed treatments for more than 45,000 children, an increase of 5% on the previous year

Creating better value for you Used 4000 fewer Sharps Bins to discard needles and other sharp items


on Changed our lab forms and generated 135,000 fewer lab blood tests orders Improved blood management and transfused 5000 fewer blood products

n ering ks ed

Reduced pharmacy stock waste by 32% by changing the dispensing practices and processes Ordered 6600 fewer mid-stream urine tests


Saved 3500 units of red blood cells, almost 1400 fresh frozen plasma, 20,000 hours of patients’ time and 3700 hours of nursing time – resulting in more than $2.7m in savings thus far

Links to other documents This Quality Account is aligned with our Annual Plan, our Statement of Intent and the Northern Regional Plan, copies of which are available on the publications page of our website

The team behind these Quality Accounts A project team led by our Quality Manager, Andrew Keenan, was responsible for the development of this document. The team would like to thank the staff who took the time to provide information about their particular project or initiative; we recognise you have important day jobs and your time is appreciated. The project team membership included: Dr Andrew Old, Clinical Lead Concord Performance Programme; Dr Colin McArthur, Clinical Advisor, Quality & Safety; Dr Andrew Jull, Nurse Advisor, Quality & Safety; Mark Fenwick, Communications Manager; Tony O’Connor, Planning and Engagement Manger; Suzy Haden, Project Manager, PwC; and Carley Young, Ten Four Communications. Next year we would like to extend membership of the project team to include consumer representatives – specifically ex-patients and family members of patients who can provide a patient view on our pursuit of quality health outcomes.

Have your say We want to know what you think of our first Quality Account. Your feedback is important and will help us to make improvements for next year. You can let us know what you think by emailing or you can write to the Quality Manager, Auckland District Health Board, Private Bag 92189, Auckland Mail Centre, Auckland 1142. A copy of our Quality Account is available on the Auckland DHB website at or you can request an additional hard copy by emailing If you’d like to provide feedback on a matter not associated with this document, details on how to do this are included on the Contact page of our website –


Areas for improvement The staff at Auckland DHB work hard to deliver the best possible healthcare, but we know there is always room for improvement. During the past year there were areas where we did not do as well as we would like and this section acknowledges this and seeks to provide some context. Particular areas of concern were patient privacy, how we manage complaints and open disclosure.


Patient privacy is of paramount importance, yet in the 2012/13 year we fell below our expectations to meet the information governance standards expected of an organisation of our stature. We need to more reliably demonstrate that we are trusted stewards of not only our patients’ health, but also their health information. A number of events highlighted weaknesses in this area during the reporting year and as a result we are investing in ensuring our patients’ privacy is maintained. With the advent of electronic technology, we have improved our clinicians’ ability to transfer clinical information, but it’s not without risk. We are taking a number of careful steps in improving our support for clinicians in this respect. In addition to reminders that patient privacy is the priority of each and every DHB staff member, on the practical front we will be supplying staff with encrypted data sticks and ensuring password protection on mobile and remote devices. During the 2012/13 year we received 832 complaints from our patients. The majority of complaints were about accessibility, care and communication. We know we need to do better in terms of how we handle complaints and our timeliness in responding to them. Historically our complaints process has been too formal in that we have largely corresponded with complainants by letter and used clinical jargon that may be inappropriate for lay people.

We have already begun to make changes. These include simple things like trying to meet with people face-to-face more often so we can better understand their issues and hopefully come to a resolution more swiftly. Another area where we can do better is around open disclosure. We need to be more open, honest and timely when things go wrong in a clinical setting. We know our clinicians need to be more proactive in telling patients and their families of issues and we are equipping them with the tools to do this, such as investing in training programmes that provide our staff with the skills to have those difficult conversations should the need arise. Auckland DHB is a large and complex organisation and while we are committed to delivering a high quality health service, unfortunately there are times when we do not always get it right. We are acutely aware of the importance of acknowledging this as part of our quality journey because without this type of critical analysis and reflection it is difficult to make positive change. We value input from the Auckland DHB community – both brickbats and bouquets – because without feedback we are unable to critically examine our performance. Details on how to give feedback on this document, and our service in general, are included on page five.


Improvement culture is embedded at Auckland DHB. Here are the five winners from the 2013 Healthcare Excellence Awards, the culmination of a programme of performance improvement that is covered in more detail in chapters six and eight.


Who makes up the Auckland District Health Board community?


The population is diverse and has varied health needs, with cancer and heart disease remaining the biggest health problems for our district. Our aim is to see all our community living healthier lives, less burdened by disability. Working together, we will help people self-manage their care and provide better health prevention advice and support.

There are 464,000 people living in our district and this number is predicted to grow by 19% or 86,000 more people by 2026.

We are relatively young:

There are more than 464,000 people living in the Auckland District Health Board district, and this number is predicted to grow by almost a fifth (86,000 more people) by 2026.

10% of the people domiciled in the Auckland DHB district are aged 65 years and over, compared with 12% of New Zealandâ&#x20AC;&#x2122;s population.

17% are aged under 15 years, compared with 22% for all of New Zealand.


Māori people are estimated to number 36,000

We are diverse:

52% Pakeha 29% Asian 11% Pacific 8% Maori 2% other In the 2006 census: Maungakiekie-Tamaki was the most deprived ward in our district with 67% of people living in an area ranked more than 6 on the NZ deprivation index (out of 10).

The least deprived ward was Orakei with 8% of this population living in an area ranked more than 6.

or 7.9% of the total Auckland DHB population.

Pacific people are estimated to number 52,000 or 11.2% of the total Auckland DHB population. This group is characterised by a great diversity of culture, ethnicity and language.

More than a third of our children (38% of all 0–14 year olds) live in the most deprived areas of the city (NZ deprivation index 9 and 10).

Asian people make up 29% of Auckland’s population 36% of these are South Asian, and about 80% of this group are Indian.

Of that 38 percent, 72% are Pacific, 49% are Māori and 21% are ‘others’.

Auckland has more non-English, non-Māori speaking people,

13% of our population need assistance or interpreting when attending health services.

with more than 100 different languages spoken. 39% of our population lives in areas with a New Zealand deprivation index of less than seven (10 is the most deprived).



Keeping our patients safe Patient safety is our number one priority and the responsibility of everyone across the organisation. Our aim is to eliminate avoidable harm, ensuring our patients experience the safest possible care. This chapter profiles five initiatives that have made significant improvements to patient safety in the past year.


patient safety


Introduction Despite our intentions to benefit patients through safe, highquality services, healthcare frequently causes harm. A series of major studies from multiple countries, including New Zealand, has consistently shown that 10–15 percent of hospitalisations are associated with adverse events causing harm, and of these about half of these events are potentially preventable.


At the ‘tip of the iceberg’ are those events reported annually in the Serious and Sentinel Event report where the harm has been significant. However, underlying this are large numbers of patients whose treatment has led to more minor complications such as: falls, incorrect medication and hospitalacquired infections. It’s uncommon for these minor complications to cause permanent harm or death, but they can often require additional treatment and extend hospitalisation. Not only does this have a significant impact on the patient and their family, it also represents an opportunity cost to society with less capacity to provide treatment for others. In recent years, closer attention has been given to the systems that we set around a patient’s journey, as we have recognised that human error is an inevitable part of complex processes and our systems must allow for this risk. Review of adverse events, using processes such as Root Cause Analysis, has found that communication between staff and lack of consistency in processes have been recurring themes. In this section we highlight a number of programmes we are undertaking to improve the safety of healthcare at Auckland DHB. Each of these are part of either a regional collaborative – the

northern region’s First, Do No Harm programme where we have joined with neighbouring DHBs to share and consistently apply improvement systems – or part of a recently announced national patient safety programme, Open For Better Care. Hospital-acquired pressure injuries and falls in hospital are now consistently measured and standardised risk assessments are made on patients at greatest risk. In the area of hospitalacquired infection, there is now a regular audit system for hand hygiene with steady improvement demonstrated, and the central-line associated bacteraemia (CLAB) programme has delivered consistent line insertion and maintenance techniques with a significant decrease in infection rates. Finally, a checklist approach to communication about key patient safety issues around the time of surgery and other major interventions has been widely implemented. We have really just scratched the surface of how consistency, reliability and good communication can improve patient safety and we will continue to further extend these concepts into a greater range of healthcare delivery.



patient safety


Falls Some patients fall while in hospital and, for the most part, do not suffer any harm or suffer only a minor injury. However, for a few patients, the harm from falling is much more serious, leading to delays in leaving hospital and longer rehabilitation. More than 1000 patient falls are reported each year at Auckland District Health Board facilities. A small number of these falls result in serious injury, such as a new fracture or a head injury. These serious harm falls mean the patients require further investigations (such as x-rays) and procedures (such as extra operations to repair the fracture). Falls of this nature also increase the length of time patients must stay in hospital, and delay their rehabilitation and return to normal life.


About half of all the serious adverse events reported by the DHB to the HQSC in 2011–2012 were serious harm falls. We aim to reduce the number of serious harm falls sustained by patients in our care. An improvement project was started in 2011 and identified a number of gaps, including: • no routine reporting to units about their falls rates • inconsistent identification of serious harm falls

Progress related to reducing the incidence of serious harm falls includes: • reporting fall rates to wards every month so they can track their progress • actively looking for patients who have serious harm falls so we accurately track the number of occurrences • requiring individual investigation of all serious harm falls by the unit where the patient has fallen

• no routine reporting of serious harm falls to Board and senior managers

• reviewing all serious harm falls reported by Auckland DHB to identify main causes

• inconsistent risk assessment of patients for falls

• using a standardised risk assessment tool

• inconsistent planning of care for patients at risk of falling

• using a standardised falls intervention care plan

• an absence of policies or guidelines for preventing falls.

• providing a patient and family information brochure

Since that time a multidisciplinary Falls and Pressure Injury Steering Group has been established, chaired by the Chief Nursing Officer. The Auckland DHB group has committed to the regional programme, First, Do No Harm and has rapidly redressed some of the gaps by learning from and adapting the materials other members of First, Do No Harm have developed.

• implementing intentional rounding2 in some wards, including Older People’s Health. In late 2012 Hon Jo Goodhew, the Associate Minister of Health, launched key quality safety markers, one of which is patients who fall in hospital. The HQSC expects 90 percent of all patients aged 75 or older


(and 55 or older if a Maori or Pacific Island patient) to be risk-assessed for falling. Auckland DHB audited patient records in February 2013 and found we were meeting the target less than 75 percent of the time. Since April 2013, we have audited on a monthly basis and improved each month. We are now more than meeting the HQSC target, with 91 percent of patients riskassessed in the June 2013 audit. Overall, 33 serious harm falls have been reported for the 2012–2013 year, the same number as those reported for the 2011–2012 year. The numbers reinforce that the problem is not easily solved and we are currently identifying next steps in reducing the harms our patients suffer from falling.

Auckland DHB has established a Falls and Pressure Injury Steering Group to look at ways to reduce the number of serious harm falls sustained by patients in our care, and has committed to the regional programme First, Do No Harm.

Falls among hospital patients are only part of a much larger problem, which is older people falling. Most often older people fall in their own homes, causing fractures. The first fracture doubles the risk of future fractures, but there are ways of preventing falls in the community and the serious harm that can result from falling. We hope to be able to address this part of the problem in the next year. 2 Intentional rounding is when all patients are approached every hour (when awake) to check whether they need assistance to the toilet, whether they have everything they need within reach and whether there is anything else that can be done for them.

We are now on target with 91 percent of hospital patients assessed for falling risk.

Did you know? • Most falls are thought to be preventable. Half of all falls reported to the Health Quality and Safety Commission are for patients who have had a serious harm fall. • Any fracture from falling can lead to future fractures – from age 50 the risk of future fractures doubles after the first. • In New Zealand about 100 patients each year who fall in hospital get a fractured hip, and fractured hips are associated with early mortality in older people.


patient safety


Pressure injuries Some patients develop pressure injuries while in hospital. These are caused by sustained pressure over bony parts of the body. Pressure injuries range in severity from red areas of skin to complete tissue destruction exposing tendon or bone. Common sites for pressure injuries are places with little tissue depth e.g. heels.


Pressure injuries are caused when a patient cannot move themselves to change position. This immobility can happen when patients have an operation that makes moving in bed difficult or have a disease that reduces their ability to reposition themselves. In these situations, patients have to rely on healthcare staff to reposition them. If the length of time between repositioning is too great, the pressure over bony parts of the body closes the circulation to the skin and underlying structures, causing tissue damage. The longer the interval between repositioning, the greater the pain and tissue damage. The tissue damage is called a pressure injury (or pressure ulcer) and the severity can range from reddened skin to deep ulcers. Serious pressure injuries cause pain, delay patients from leaving hospital and returning to their normal lives, increase the risk of infection, and may require surgery. Earlier efforts to reduce pressure injuries at Auckland DHB had led to the development of A+SKIN-E, an acronym

to remind healthcare staff of the range of care needed to prevent pressure injuries. As part of the regional safety programme First, Do No Harm, an improvement project was started in 2011. The project identified a number of gaps in the strategies to prevent pressure injuries, including: • no routine reporting to units about their pressure injury rates • inconsistent identification of pressure injuries • no routine reporting of serious pressure injuries to Board and senior managers • inconsistent risk-assessment of patients for pressure injuries • inconsistent planning of care for ‘at risk’ patients and inconsistent grading of pressure injuries • outdated guidelines for preventing pressure injuries.

we believe serious pressure injuries should not occur in

hospital and have classified them ‘never events’.


Pressure injuries are classified as ‘never events’

Since then we have established a multidisciplinary Falls and Pressure Injury Steering Group, chaired by the Chief Nursing Officer. We have committed to reporting pressure injuries the same way and have implemented many of the solutions used by other DHBs in the region. Progress related to reducing the incidence of pressure injuries includes: • auditing a random selection of patients every month to assess whether they have pressure injuries • reporting pressure injury prevalence for all grades of pressure injury and for the more serious of pressure injury (grades 3 and 4) • reviewing all serious pressure injuries reported by Auckland DHB to identify main causes

• implementing intentional rounding* in some wards, including in Older People’s Health. The prevalence of pressure injuries is about seven percent of hospitalised patients of all ages and the majority of these are the least severe form of pressure injury (reddened intact skin). Only one serious pressure injury has been found in the random audit since July 2012. Auckland DHB has since determined that serious pressure injuries should be considered “never events” and will be reported to the Health Quality and Safety Commission. As the most serious pressure injuries are now rare events, we will need to establish a different approach to finding such pressure injuries to ensure they are all properly investigated, if they do occur.

• using a standardised risk assessment tool across the DHB • using a standardised pressure injury prevention plan that can be tailored to the individual patient The prevalence of pressure injuries is about seven percent of hospitalised patients of all ages. We have had one hospital-acquired serious pressure injury since July 2012.

• providing a patient and family information brochure * Refer footnote 2 on page 15.


patient safety


Target CLAB Zero Central line3-associated bloodstream (CLAB) infections account for about 30 percent of all healthcare-associated bloodstream infection events within Auckland DHB’s hospitals. At best they may result in an increased length of stay and, at worst, increased mortality. It is therefore important to find ways to reduce the opportunity for these type of infections.


In 2011 Counties Manukau DHB (CMDHB) undertook a multifaceted quality improvement programme based on the approach taken by Dr Pronovost (see page 19) that, over a two-year period, saw the CLAB rate decrease from 6.6/1000 line days to 0.9/1000 line days. The same year the Health Quality & Safety Commission formed a partnership with CMDHB to deliver a national programme to reduce CLAB rates called “Target CLAB Zero”. The Target CLAB Zero programme was initially delivered in three Auckland DHB intensive care units and it is planned to be rolled out across the other units where central lines are used. Three of the intensive care units at Auckland DHB – Department of Critical Care Medicine (DCCM), Cardiothoracic Intensive Care Unit (CICU) and Paediatric Intensive Care Unit (PICU) – worked together for the first time to deliver a quality improvement initiative.

All three units have reduced CLAB rates: • CICU has not had CLAB events since February 2012 • Both DCCM and PICU have achieved greater than 100 days between CLAB events. Prior to the start of this collaboration it is estimated that the CLAB rate was approximately six events per 1000 line days in our intensive care units. The programme has reduced the morbidity4 and mortality associated with central lines and has standardised the insertion of lines across the organisation – lines placed in patients in theatre, radiology and emergency departments. 3 A central line is an intravenous line that is inserted into a large vein, with its tip near the heart, to administer medicines or fluids or withdraw blood. 4 Morbidity refers to the state of being diseased or unhealthy. Mortality is the term used for the number of people who died within a population.

Central line-associated bloodstream infections are largely preventable events. By following simple bestpractice activities we have significantly reduced their occurrence and reduced the morbidity and mortality associated with central lines.


The Auckland DHB CLAB project has improved blood culture collection practices from intensive care units so the diagnosis of a blood stream infection is able to be made more easily. It developed a form for recording the placement of Central lines for use across the organisation, and had a key role in the development of a national pack for use at line insertion.

Three of our intensive care units exceeded 100 days without a CLAB event.

In 2006 a medical researcher (Dr Pronovost) and his team reported on a quality improvement programme, known as the Keystone Project, that aimed to reduce the rate of CLAB events in the intensive care units in the State of Michigan, USA. Following this, a set of evidence-based best practices were developed that, when applied at the placement of every central vascular line (CVL), were associated with lower infection rates. The best practice activities included: • hand hygiene • the wearing of full barrier attire (gloves, hat, gown and mask) • the use of 2% chlorhexidine for skin antisepsis • using a full body drape during the insertion of CVL. All four of these activities needed to be followed to achieve 100 percent compliance. The site of placement was also considered an important variable with avoidance of femoral lines recommended. Following the implementation phase of the Keystone Project, the rate of CLAB in all units was reduced from 2.6/1000 line days to a median of 0/1000 line days, and this improvement was sustained beyond 18 months.


patient safety


Safe surgery saves lives The Surgical Safety Checklist In 2009 Auckland DHB was part of a landmark study which showed that use of a patient safety checklist in the operating room reduced deaths and complications after surgery. The challenge now is to encourage universal engagement in the use of the checklist within our DHB and beyond.


Most patients understand that anaesthesia and surgery carry risks and that complications, and even deaths, do occur in the peri-operative period (i.e. the duration of a patient’s surgical care, which commonly includes ward admission, anaesthesia, surgery and recovery).

distinct “moments” in an operation. The first of these is “Sign In” when the patient first enters the operating theatre. This check includes an identity check on the patient, and confirmation of the operation they are having (including which side is to be operated on if this is relevant).

What is less well understood is that errors or omissions by medical staff may increase the risk of some of these complications. For example, the risk of post-operative infections is higher if the anaesthetist forgets to give an antibiotic at the start of the operation. Some errors can even cause direct harm, such as a patient receiving the wrong operation.

The second is “Time Out”, intended to be performed just prior to the first surgical incision. This vital check includes a requirement for every member of the theatre team to introduce themselves by name and role, and a discussion about any anticipated critical events.

While errors can never be eliminated from any human activity, as a responsible profession we must take all practicable steps to minimise them. In the mid 2000s the World Health Organisation (WHO) recognised that errors and omissions leading to complications in the perioperative period were a significant global health issue. Their response was to draw an international panel of patient safety experts together to discuss ways this could be mitigated. The WHO Surgical Safety Checklist arose out of this initiative. The checklist is comprised of a series of items that must be read out at three

The third and final moment is “Sign Out”, intended to be performed before the patient leaves the theatre at the end of surgery. This check includes a discussion among the teams about important aspects of the patient’s post-operative care.

The use of a simple, cheap intervention (the checklist) appears to impart significant gains in patient safety in the peri-operative period.


Auckland City Hospital was one of eight centres worldwide that participated in a study to assess the impact of introducing this checklist on rates of peri-operative complication and death. The study looked at outcomes for 4000 patients undergoing surgery before adoption of the checklist, and then a further 4000 patients after its adoption. The results, published in the New England Journal of Medicine in 2009, revealed that introduction of the checklist appeared to have almost halved the proportion of cases ending in death, and to substantially reduce the proportion of patients experiencing a post-operative complication. This stunning result was replicated in a second study by an independent group of researchers published a year later.

Ninety nine percent of patients now have crucial checks on their identity and intended surgical procedure on entering the operating theatre.

Not surprisingly, Auckland DHB has mandated that the checklist be used for all surgical procedures at Auckland City Hospital, and attention has turned to ensuring its correct administration. A published audit in 2010 revealed that “Sign In” was undertaken in 99 percent of cases and “Time Out” in 94 percent. Alarmingly, the “Sign Out” procedure was being undertaken in only two percent of cases.

Checklist used at Auckland City Hospital.

A 2012 audit revealed maintenance of the excellent figures for the first two moments, and an improvement in Sign Out to 22 percent, but further gains are needed. Increasing the use of the surgical safety checklist is a work in progress in 2013. In particular, we are preparing an initiative to improve leadership during the administration of all three areas of the checklist by cycling the responsibility around all teams present. Our own research has shown this works well in other hospitals.


patient safety


Hand hygiene Auckland DHB is the lead agency for Hand Hygiene New Zealand (HHNZ), one of three national infection prevention programmes initiated and funded by the Health Quality & Safety Commission. HHNZ has been highly successful and is the driving force behind unprecedented improvements in hand hygiene practice within New Zealand DHBs during the last year.


The overarching goal of the HHNZ programme is simple but ambitious: “To improve hand hygiene practice of healthcare workers in the New Zealand Health Sector and thereby improve health outcomes for the patients we serve”.

The benefits of improved hand hygiene practices are many, including:

Hand hygiene is one of the most important measures in the fight against healthcare-associated infections, making it a key patient safety issue within New Zealand hospitals. Performing hand hygiene correctly at each of the five World Health Organisation (WHO) recognised “moments” reduces the risk that infectious organisms will be spread between patients on the hands of healthcare workers.

• improved patient outcomes

Key components of the HHNZ programme include: • ensuring that alcohol-based hand rub is consistently available at the point of care • comprehensive education of all healthcare workers about the standard of hand hygiene that is expected of them; and • regular auditing and feedback of hand hygiene performance to clinical staff and management.

• a reduction in infection rates of harmful bacteria and viruses encountered in the healthcare setting

• reduced cost. Another benefit is the reduction in bloodstream infections. Preliminary data both at Auckland DHB and nationally suggests a downward trend in the rate of healthcare-associated bloodstream infections with Staphylococcus aureus (a bacteria that is one of the most common causes of healthcare-associated infections in New Zealand and worldwide). During the last year HHNZ has achieved several milestones, including the establishment of a robust national audit system for tracking hand hygiene compliance, with more than 100 trained and certified auditors nationwide. There has also been an unprecedented level of engagement,

Quite simply, clean

hands save lives.


coordination and collaboration between all 20 DHBs with respect to improving hand hygiene practice. Successes and innovations at individual DHBs are celebrated and shared nationally through HHNZ’s monthly e-bulletins and quarterly “Hand Hygiene Chronicle” publications. Many of these successes have occurred at Auckland DHB, which has raised the profile of the organisation and put it on the map as a centre of excellence when it comes to infection prevention.

Minister of Health, Hon Tony Ryall, practising hand hygiene on a visit to Auckland City Hospital.

New Zealand DHBs are currently on track for a hand hygiene compliance rate of 70 percent using the WHO five moment audit tool. If this is achieved it will be a first for the New Zealand healthcare sector.

Most importantly, we now have robust evidence that the programme is effective and is making a difference. The latest audit showed a national compliance rate of 67 percent, which is an improvement on the 62 percent for the previous quarter. Preliminary figures for the June 2013 audit show that we are on track for more than 70 percent compliance. Importantly, during the last audit Auckland DHB had the highest level of hand hygiene compliance in the country. We believe this achievement can be attributed, at least in part, to our position as the lead agency of the HHNZ programme. There are 20 DHBs across New Zealand and Auckland DHB moved from fourth best in terms of hand hygiene in October

During the last audit Auckland DHB had the highest level of hand hygiene compliance in

the country.

2012 to first in March 2013. This improvement occurred in parallel with a highly significant improvement across all 20 DHBs nationally, from 62.1 percent compliance in October 2012 (18,095 of 29,128 moments) to 66.7 percent in March 2013 (20,119 of 30,196 moments).

Did you know? All 20 DHBs are actively contributing to, and participating in, the national HHNZ programme. The level of collaboration between the infection prevention and control teams throughout the country is in many ways unprecedented and is generating a great deal of energy and enthusiasm nationally. Public messages of endorsement and support for the programme have come from numerous DHB executives and clinical leaders throughout the country as well as from Hon Jo Goodhew, the Associate Minister of Health.





Better quality care and patient experience Every contact with our patients will be as good as it can be, that’s our collective aim. We work hard to provide effective, accessible and patient-centred care that is delivered in an integrated way. Integration – all of our departments working together for the benefit of the patient – is central to an excellent experience. This chapter outlines four initiatives that have been undertaken with the express aim of improving the patient experience.

Members of the Starship team (L-R): Kathy Peacock, Jan Tate, Sue Whaitiri, Nicole Pasfield, Sandra Murphy, Cath Byrne, Una Wainivetau and Fiona Haylock.


Better quality care and patient experience


The Patient Experience Survey District Health Boards are required to survey their patients on their experiences following a hospital stay, and until recently, most patient surveys at Auckland DHB were conducted via post with survey forms mailed to patients on their return home.


In 2011 Auckland DHB began using an online survey tool to find out what our patients think. Not only is this quicker and more convenient for many patients it also enables us to get feedback and respond to it more quickly. Putting ourselves in our patients’ shoes is critical and the Patient Experience Survey helps us to do just that. We hear directly from our patients about what is most important to them, what could be improved, and their overall satisfaction with their care and treatment. Our patients’ voices are important, and the survey provides them with an opportunity to provide feedback in their own words. Since implementing the online survey in September 2011 we have received 5581 responses. From these responses our patients have told us there are three things that make the most difference to their care and treatment:

1. Communication (clear answers patients can understand) (51%) 2. Feeling confident about the quality of their care and treatment (46%) 3. Getting coordinated care (41%).

Putting ourselves in our patients’ shoes is critical and the Patient Experience Survey helps us to do just that.


Of the 5581 responses to date, 82 percent rated their care and treatment as “very good or excellent”. Those who rated their care and treatment as excellent said that staff: • responded to them individually and understood their needs • interacted with them in a warm and friendly manner • were caring and kind towards them and showed compassion • appeared to be genuinely concerned and interested in their welfare and wellbeing • were motivated by this compassion to provide great care and treatment, make them comfortable, and reassure them • were helpful, responsive and anticipated their needs • worked well together. Ward 64 haematology Staff Nurses Karen Shaw and Claudia Kelsall.

The survey is a key tool in our pursuit of continuous improvement. It assists us to understand how we are doing and to identify areas for improvement. In fact, we are seeing an increase in staff referring to the data when an issue arises to see if our patients have already shared any insights. With the inpatient online survey working well, we recently piloted an online survey with a number of outpatient clinics (orthopaedics; ear, nose and throat; and ophthalmology). The pilot was successful and we are planning to roll out the online survey capability to additional outpatient clinics in 2013/2014.


Better quality care and patient experience


Advance Care Planning Advance Care Planning is about helping people articulate what matters most to them, particularly as they approach the end of their lives, and working with them and their families to plan and deliver care that allows the person to live their best with what life they have left.


Eighty five percent of people die of chronic illness and up to 50 percent of us are not in a position to make our own decisions when we are near death. People do not talk about or plan for what kind of care they want as they approach the end of life and, as a rule, healthcare professionals do not encourage conversations with people to determine what is important to them. Consequences of not planning for future care could mean that: • the person receives unwanted treatments that do not maintain or enhance their desired quality of life and may in fact prolong dying • the person dies in hospital away from loved ones and familiar surroundings • the person’s family is exposed to the unwanted responsibility of having to choose for the person without knowing what they might have wanted, which often increases stress and anxiety and may complicate and prolong bereavement. We have put in place a multi-faceted approach to improve our services for patients and their families as they approach the end of life. Overcoming the taboo associated with talking about the end of one’s life is a key part of this

project. The project team has engaged with staff to encourage them to open up and talk about the end of life. This has involved obtaining the support and involvement of senior management, the healthcare workforce and other support staff in determining what matters most to our patients and working with them to achieve that.

Overcoming the taboo associated with talking about the end of one’s life is a key part of Advance Care



Advance Care Planning Deployment Model Health workforce – engage, train and support to initiate, participate and facilitate ACP; provide tools and information resources

Organisational – getting and retaining the support and involvement of healthcare leadership Community – reaching out to the general public to engage them in ACP development, deployment and participation



People – inform them of ACP and the benefits; provide information resources and tools to guide and record ACP

People, patients, families and whanau

To ensure treating clinicians and other healthcare workers are aware of the person’s preferences and Advance Directives

System infrastructure

Continuous quality improvement

Fostering a health workforce culture of continuous quality improvement

Developing and testing measurement and evaluation tools, taking lessons learnt and applying to practice improvement

Underpinned by a conducive policy environment and availability of human and financial resources Adapted from Health Canada, March 2008

• 799 advance care planning conversations were held in the six months from July 2012. • During the past year, 66 staff trained as ACP practitioners with advanced communication skills.

Advance Care Planning is about helping people articulate what matters most to them as they approach

the end of their life.

From a community perspective, we have sought to engage patients and their families in advance care planning by raising awareness, initiating dialogue and connecting people to relevant organisations and services. We are training and supporting our healthcare workforce to initiate advance care planning conversations so they can work with our patients as they formulate their future treatment preferences. During the past year, 66 staff trained as Advance Care Planning (ACP) practitioners with advanced communication skills. In addition, the project team has worked with patients, their families and carers in developing information resources (see that are readily available for consumers and the healthcare workforce.

We are working to ensure we have mechanisms in place to support advance care plan recording and access. We record the initiation and facilitation of conversations in clinical notes, including some details of what was discussed, to ensure we have a record of the context for further conversations and eventually to assist in the development of an Advance Care Plan. Continuous quality improvement has been integrated into advance care planning from the outset. More information about advance care planning can be found at



Better quality care and patient experience


Valuing our patients’ time Acute patient flow Valuing our patients’ time is our approach to finding and reducing all of the things that our patients wait for over the course of their hospital stay. Our patients now spend less time in the emergency department (ED), less time being admitted and being seen, and spend less time on wards. Overall, they are spending less time in hospital. This whole-of-hospital approach has improved our patients’ experience and quality of care, and enabled us to achieve the ‘Shorter Stays in Emergency Departments’ National Health Target.

Ward 68 daily rapid rounds The rapid rounds model encourages communication between members of the healthcare team, resulting in quick referrals, less waiting time for patients and earlier discharge.


What a difference three years can make 2009

20.4% 1,514

7hrs 31 mins 9hrs 20 mins 6hrs 50 mins 8hrs 50 mins



General medicine patients


Rapid Rounds means we get the discharge date right for our patients, it means patients know in advance when they will be going home. Previously they didn’t always know until the same day.

0.6% 54

1hr 28 mins 1hr 40 mins

Orthopaedics patients

1hr 20 mins

General surgery patients

1hr 19 mins

– Paul Birch, Allied Health

People, patients, families and whanau

Since 2009 we have been working hard to find ways to reduce the amount of time our patients wait for our services and reduce their overall stay in hospital. We have implemented a number of initiatives that recognise and value our patients’ time and, as a result, we System have saved thousands of bed days for infrastructure inpatients and reduced the ED length of stay by 34 percent. This drastic improvement has not only improved the quality of care we deliver, but it has also allowed us to accommodate a 25 percent increase in patient presentations to ED over the same period without increasing the size of the department.

Some of the improvements that have reduced the duration of our patients’ hospital stay include: • improvements to the triage process and physical changes to the registration area to make it easier and simpler for patients • faster completion of initial ED assessment and treatment • streamlined process for transferring patients to wards, with a 70 percent reduction in the number of actions required • better planning of a patient’s ward stay, including the introduction of “Daily Rapid Rounds” – a structured multi-disciplinary team meeting to discuss a patient plan for their stay



Shorter stays in the adult emergency department 2008







• increased rate of weekend ward discharging from inpatient wards


• improved understanding and followup on extended length-of-stays in ED • better understanding of expected demand, including the introduction of flexible bed capacity to accommodate known or unexpected demand peaks.





% of <6 hour Emergency Department stay


• improved visibility of hospital occupancy, including the development of a “Bed Status at a Glance” website accessible by any staff member via the intranet to instantly identify available beds

The graph shows the percentage of patients who spent less than six hours in the emergency department. The six hours is calculated from the time the patient presents to the time they are discharged, admitted to the hospital or transferred to another care facility. Our goal is for 95 percent of adult patients to spend six hours or less and we have been consistently around this figure for the past year.

I can’t believe how quick it was to get up here… last time I waited nearly two days to get to the ward; this time I was up in the ward within three hours of arriving at

the hospital. – Patient, Ward 65


Case study: Daily rapid rounds It became apparent that patients were staying longer in hospital as a result of inadequate communication between doctors, nurses, Allied Health5 and other multidisciplinary team members. Our solution was to implement ‘Daily Rapid Rounds’, a short daily ward meeting with nurses, doctors, and Allied Health to coordinate patient plans for their hospital stay and make the plans visible in real-time on a patient-status-at-a-glance board. The result is improved team communication, quick referrals, and quick problem solving, which means patients wait less and are ready to go home earlier. 5 Allied Health is a term used to describe health professions distinct from medicine, dentistry, optometry and nursing. For example, occupational therapy, physiotherapy and social work.

In 2012, patients spent 133,000 fewer hours waiting in ED compared to 2009. This includes: • 54,212 fewer hours spent waiting to be admitted to an inpatient bed – that’s a saving of 2,259 days or 6.2 years • 7,411 fewer hours spent waiting to be seen by an Inpatient Specialty Clinician.


Better quality care and patient experience


Patient engagement and co-design At Auckland DHB we are building patient, family, wha- nau and community relationships within our hospitals and the wider community so that we better understand the patient experience and what’s important to people. We are using a framework called co-design, which is about staff, patients and other stakeholders working together to achieve the desired outcome. While improving service quality and safety is an important goal, we ultimately want to empower people so they can manage their own health with our support.


Relationships with patients, families and communities are integral to both learning about and improving patient experience. To strengthen our patient and community relationships, we have: • participated in the Health Quality and Safety Commission’s ‘Partners in Care’ programme

• rolling out 24/7 visiting for a lead patient support person in recognition of the role family and friends play in patient care • including ‘co-design’ in staff service improvement training. Notable activity includes:

• created the ReoOra/HealthVoice online community panel, which currently has 396 members

• Advance Care Planning training was completed by 66 staff in 2012/2013, and is ongoing.

• established ‘Local Health Partnerships’ across the Auckland DHB district to help drive locality planning

• Conversations that count is a community-based project to encourage conversations about death and dying amongst families and in communities so that people can plan for their deaths and get the care they want at the end of their lives. In the 2012/13 period, the team developed a 52-page toolkit with 18 session modules, developed and delivered two, two-day training sessions to 27 volunteers, and piloted education sessions in the community. Funding is now secured to develop and deliver a pilot train-the-trainer programme.

• developed Patient Experience Survey monthly reports that highlight our patients’ experience across the most important dimensions of their care. To further integrate patient, family and community relationships into decisionmaking and service delivery, we are: • developing a Patient and Family Experience Programme to integrate and focus our patient, family and community engagement activity • linking ‘Local Health Partnerships’ into the governance of our localities programme

It wasn’t difficult to convince people to participate – they are thrilled to be asked.


Some of the Cardiac co-design project group: Annette Reif, Heather Spinetto, Rachael Narbey and Dr Tim Hornung.

Case study: Patients get to the heart of the matter There can often be many health professionals involved in a patient’s care, but it is usually only the patient who will see the whole process from start to finish. This means patients and families are in a unique position to see how the different parts of the care process work together and where improvements can be made, and this is why it makes sense to involve them in quality improvement.

• Bone Marrow Transplant Haematology Ward redesign – the team used the principles of co-design to conduct a series of interviews with ten patients and six family members. The interviews sought to understand patients’ experiences and use these to inform the physical design of the new Bone Marrow Transplant Haematology ward and the way services are delivered. The emerging themes were: • A welcoming environment • A family-friendly environment • A compassionate environment

One of the ways we have been doing this is through co-design, a tried-and-tested method used in other organisations, both here and overseas. Traditionally, we have involved patients and the community in planning and improvements through a survey, focus group or interview. However, co-design is different; it keeps patients involved throughout the entire process and gives everyone an equal opportunity to contribute.

• A nourishing environment

During the last three years co-design has become more common as an approach to service improvement at Auckland DHB. One project beginning to reap the rewards is the transition of patients from paediatric to adult cardiac services. Grounded in patient and family feedback, the first step to improving the transition from paediatric to adult cardiac services will be providing better information for parents and patients. Around the world, it is increasingly recognised that transition is an important part of the ongoing care of patients with chronic diseases and that appropriate resources and planning are necessary to optimise this process.

The findings are being incorporated by the project team responsible for designing the new ward.

A Regional Family Support Coordinator for a community organisation that supports families of children with heart problems (who is also a mum of a teenager with a heart condition) has been involved in the project. She told us, “Using co-design has allowed patients and parents, like me, to tell our stories of the service as it currently stands. The [community] organisation played a key role in helping Auckland DHB identify consumer representatives. It wasn’t difficult to convince people to participate – they are thrilled to be asked.”

• A quiet environment • A connected environment.

What’s next – partnering to develop an ethical framework Last year’s national ethics review concluded that health research ethics committees will no longer review activity targeted at health service planning or improvement. Instead, the responsibility for ethical conduct now lies with the investigators and their organisation. We are exploring possible partner agencies to assist the DHB to define and integrate a set of ethical principles that can be used to assess the ethical merit of projects and programmes. The establishment of an ethical framework will expedite patient and community engagement, exhibit a sense of social responsibility and foster community participation.


Better quality care and patient experience


Surgical Performance programme Elective surgery discharges for the Auckland DHB population have grown by more than 25 percent since 2009/10 from 9425 to 13,499 in 2012/13. Also in this period, maximum wait time targets for initial assessment and surgery have been introduced. Within this context we are pleased to report that we have achieved a situation where no patient waits more than five months for either step.


The significant growth in elective surgery requests, coupled with increased volumes from other DHBs (more than 50 percent of our work is for other DHBs), was the reason behind the introduction of a number of local and organisationwide initiatives to manage volumes safely while maintaining the standard of service and outcomes patients expect from us. Three examples are outlined below.

A better pre-admission experience Before surgery, every patient goes through a pre-admission process to make sure they are ready and it’s safe for surgery to go ahead. At a pre-admission check, patients could spend at least 35 percent of their time waiting to be seen. When you add this to the time spent with the doctor or nurse, and the travel time, it’s obvious that pre-admission checks could take quite a chunk out of a patient’s day. In January 2012, the ear, nose and throat service trialled a new phone pre-admission process that saw patients triaged based on their health status and the complexity of surgery, with lowerrisk patients having their pre-admission appointment over the phone. The new process has had a positive impact with up to 40 percent of patients now being phoned. This is more convenient

for patients and frees up clinic time so that patients who do have to come in for a pre-admission check are experiencing a faster process. Another benefit is the bigger pool of patients that are now ready for surgery. This means that if a patient scheduled for surgery cancels, there are others ready to take their place. The trial has been so successful that it is now being rolled out to other areas across the DHB.

Production planning and outpatient work ensures we organise ourselves to deliver the service at a time convenient to the outpatient, first time and on time.


Enhanced recovery after surgery Helping our patients post surgery is an area where significant benefits can be made. One procedure recently reviewed was for primary hip joints (Unilateral Primary Hip Arthroplastys). Auckland DHB conducts around 200 of these each year and patients stay almost twice as long post-surgery as the Australian benchmark. To reduce the length of stay, and improve patient certainty through the process, we have made changes to this pathway. These changes include creating a more specific plan for patient mobilisation post surgery and identifying a target discharge date. Initial results are positive with patients provided greater certainty as to how and when their surgery and recovery will proceed and more than a day’s reduction on average in length of stay, meaning patients are able to go home sooner. In addition, patients now receive a postoperative call 48 hours after discharge to confirm they are comfortable.

Production planning and outpatient performance – increasing convenience and certainty for patients During the past two years we have worked on internal routines to improve how we schedule patients through outpatient appointments and surgery. The objective is to ensure that even with increased volumes, we are able to maintain appropriate wait times including for those very ill patients who need to be seen with urgency. Ultimately we would like to be able to let patients choose their own appointment times, which would reduce the rate of missed appointments. In addition, we are working to ensure all available resources are fully used, including new operating rooms and beds opened at Greenlane in 2011.

On average, changes to the way we treat patients requiring hip surgery has reduced the length of stay by more than a day.


Better quality care and patient experience


Cancer treatment waiting times Cancer remains one of the biggest health problem areas for our district and accounts for about one third of all deaths. In the 2012/2013 year we have focussed our efforts on achieving shorter wait times for cancer treatments, in line with national targets, and implemented a number of patient-centred initiatives, some thanks to last year’s successful Dry July campaign.


The national health targets for 2012/2013 required DHBs to work towards providing radiation or chemotherapy treatment within four weeks, a goal that Auckland DHB’s cancer services teams achieved 100 percent. This is a fantastic result, particularly given all patients, apart from one, were treated in-house. This is a significant improvement on previous years when we have outsourced a proportion of these treatments to private service providers to meet required timeframes. The teams in cancer services have worked hard to build our internal capacity so we can provide these important treatments for our patients. Data collection has been a focus for the Regional Cancer and Blood Service. We have been collecting data as part of the Regional Implementation Plan for the Ministry of Health’s Faster Cancer Treatment indicators and have been working towards the 62 day cycle i.e. 62 days from referral to first treatment. We know that we don’t meet this target 100 percent of the time, but collecting the data has provided us with an opportunity to identify barriers within each cancer pathway and opportunities to remove them. It has also enabled us to ensure we have systems in place to capture the stages in each patient pathway i.e. referral, first specialist

appointment, decision to treat and treatment date etc. This is the first step in the development of a comprehensive cancer treatment database that will allow clinicians and managers to understand where barriers to timely treatment exist and identify ways to reduce these. In respect of lung cancer, we have been working to the 62 day target for the past three years now. We have made progress and have steadily increased to approximately 65 percent in the 2012/2013 year. In the Northern region, a lot of effort has gone into improving cancer multidisciplinary meetings (MDMs). MDMs are a regular, face-to-face (or videoconference) meeting involving a range of health professionals with expertise in the diagnosis and management of cancer. In the case of lung cancer, the MDM participation has increased from 28 percent in 2004 to approximately 80 percent in the 2012/13 year. Those discussed at an MDM were eight times more likely to have a cyto-histological6 diagnosis than those not discussed. 6 A cyto-histolgical diagnosis is a pathological diagnosis, which is ‘gold standard’ and allows for tissue diagnosis and details for more specific treatment.


Case study – Dry July delivers for our cancer patients The Dry July campaign is bearing fruit for our cancer patients in the form of 30 new chemotherapy treatment chairs that have recently arrived from Germany. The custom-designed blue chairs – costing $8,000 each – are considered the best money can buy and are already in use at the Regional Cancer and Blood Service in Building 8 on the Grafton site. They have replaced old recliner chairs that weren’t ideal due to their limited range of positions and the fact they could not be laid flat in the event of an emergency.

Cancer patient Kelvin Twist sits with Clinical Director Dr Richard Sullivan while receiving treatment in one of the new chairs purchased with funds from the 2012 Dry July campaign.

Auckland DHB is responsible for all non-surgical cancer treatment for its own population and that of Waitemata, Counties Manukau and Northland DHBs, which means for some patients travel is largely unavoidable. We are seeking to reduce the travel required, particularly for Northland-based patients, through our tele-health project currently being piloted in Whangarei. Through the use of video-conferencing technology, we are able to connect an Auckland-based clinician with a patient and nurse based in Kaitaia, for example,

and conduct a clinical appointment. This reduces travel time, cost, and stress for the patient, ultimately making a big difference to the patient experience. In September we are opening a head and neck clinic at Auckland City Hospital that brings together dieticians, dental surgeons, radiation specialists and medical oncologists. This ‘hub’ will provide a one-stop-shop for the patient and a familiar environment within which to receive treatment. Following the head and neck clinic we are planning to open clinics for lung and gynaecological cancer.

Approximately75% of cancer patients seen in the 2012/13 year with confirmed cancer diagnosis received their first cancer treatment within 31 days of the decision to treat.

“The new chairs are just fantastic and patients are certainly noticing the difference,” says the service’s Clinical Director, Dr Richard Sullivan. “It’s great to really see patients getting the benefits of all the fundraising so many people did as part of our Dry July campaign last year.” Other projects implemented with funds from the fundraiser include the installation of Wi-Fi in cancer wards, waiting rooms and treatment areas; the purchase of 70 new televisions for use by cancer patients, and a major garden renovation. Dry July is a non-profit organisation that aims to improve the lives of adults living with cancer through an online social community giving up alcohol for the month of July. Its mission is to directly benefit adult cancer patients by providing funds to create better environments and support networks for patients and their families. The organisation also seeks to raise awareness of drinking habits and the value of a balanced healthy lifestyle. Last year, Auckland DHB’s Regional Cancer and Blood Service was the first in New Zealand to run Dry July and raised $560,000 for its efforts. This year the service has been joined by the cancer services in all DHBs in our northern region, and cancer services in Wellington and Christchurch.





Healthier communities All our community living healthier lives, less burdened by disability â&#x20AC;&#x201C; another of our collective aims. Healthy communities rely on efforts from the health provider (us) and the people we serve. We have a strong belief in the benefits of partnership; working within our communities to provide better health prevention advice and support, and helping people to self manage their care.

Organ Donation New Zealand staff promoting Thank You Day 2012. Pictured (from left): Margaret Kent, Team Administrator; Dr James Judson, Medical Specialist; Melanie Stevenson, Communications Advisor; Janice Langlands, Team Leader and Donor Co-ordinator; and Mary Oâ&#x20AC;&#x2122;Donnell, Donor Co-ordinator.


healthier communities


Immunisation By working with our primary care partners, Auckland DHB has achieved excellent results in the immunisation coverage rate for children, ensuring they are protected from common communicable diseases7 and exceeding national targets.


Until 2012, the national immunisation target was for 95 percent of all two-yearolds to be fully immunised. Auckland DHB exceeded this target by achieving 96 percent, which was the result of a committed effort from a wide range of people both within the DHB and in primary care. Although the target was achieved it was noted that many families were late in beginning the immunisation schedule for their babies and this left many unprotected at a time when they were particularly vulnerable. As a consequence, the Ministry of Health changed the target to 85 percent fully immunised at eight months. In May 2013, we had exceeded the new immunisation target by five percent with a 90 percent coverage rate.

This was achieved by working with our primary care stakeholders on the following actions: • ensuring 90% of newborn children are enrolled with a GP and Well Child provider at birth, by recording enrolment details on the maternity services birth event booking form • improving access to, and coordination of, immunisation services through a coordinated, collaborative service delivery and governance model that identifies and addresses service delivery gaps and issues across the region and across all primary care providers, with a particular focus on Auckland and Waitemata DHBs

We have made excellent progress in the area of child immunisation. The aim for the 2012/2013 year was to see 85 percent of children in the Auckland DHB area fully immunised at eight months of age. At 30 june 2013 we had exceeded this target by 5 percent.


â&#x20AC;˘ giving PHOs8 representation on the Auckland Regional Immunisation Operations Group in order to focus on practical systems-related strategies for improving coverage. This group will report to the Auckland DHB Immunisation Governance Group, bringing together all immunisation stakeholders to monitor performance and take a DHB broad systems perspective on improving coverage â&#x20AC;˘ providing PHOs with regular practicelevel immunisation coverage data and analysis so PHO Immunisation Coordinators can identify ways to address any issues and improve coverage.

7 Also known as infectious diseases or transmissible diseases. 8 PHO stands for Primary Health Organisation. PHOs support the provision of essential primary health care services through general practices.


healthier communities


Cardiovascular risk assessment screening programme Cardiovascular disease (CVD) is a leading cause of morbidity and mortality in New Zealand. It accounted for 45 percent of female deaths and 43 percent of male deaths in 2008, yet is largely preventable. Maori and Pacific peoples are disproportionally affected, as are those with low socioeconomic status.


Screening for CVD risk is a key intervention. The Cardiovascular Risk Assessment (CVD RA) programme is an important screening programme that helps identify people who have an increased risk of having a CVD event. It is an effective tool that helps us to intervene earlier, reducing the burden on the individual and family and the wider health sector. The benefit of assessing CVD risk is to identify those people at risk and give them lifestyle choices and management options early to reduce the likelihood of developing the disease and improve quality of life. While some risk factors are static, such as age and ethnicity, simple lifestyle changes such as increasing exercise, quitting smoking and a modified diet can be incorporated with success. The Ministry of Health recognises the high morbidity and mortality rates for patients with cardiovascular disease and has set targets for DHBs in New Zealand. The first target is to screen 75 percent of eligible patients who are enrolled in a general practice by June 2013. In December 2012, Auckland DHB rated 17 out of the 20 DHBs in New Zealand with a rate of only 54 percent of eligible patients screened. Since December our screening rate has risen to 78 percent, which means we have exceeded the target. However, the national target will increase to 90

percent in June 2014, which means we still need to improve. In the case of Pacific peoples, we exceeded the national target in May with 77 percent of our eligible population screened, and were the first DHB in the country to achieve this. This is an excellent result particularly given the high rate of cardiovascular disease in the Pacific Island community. Measures taken by Auckland DHB to address the gap in our screening target and achieve a sustainable screening practice include: â&#x20AC;˘ Encouraging practices to take bloods within the practice setting rather than sending a person to a laboratory as this has been highlighted as a reason for incomplete assessments. â&#x20AC;˘ Exploring screening practices in workplaces and other community settings. This involves working with industries and unions in partnership with the Auckland DHB to continue to offer screening in workforces that have traditionally had large numbers of the eligible population who are not able or motivated to visit their doctor. Point-of-care testing has also been explored to assist where lab testing of blood results is not practical or viable.


Auckland DHB staff member, Nona Utumapu, having her CVD risk assessment at the Greenlane Clinical Centre during a free staff assessment campaign.

Current eligible population for CVD risk assessment screening

Maori, Pacific Island and Indian subcontinent

women aged 45–74

Maori, Pacific Island and Indian subcontinent

men aged 35–74

All other ethnicities

All other ethnicities

men aged 45–74

women aged 55–74

• Exploring screening within the Auckland DHB workforce. We strive to lead patient self-management initiatives and encourage people to take responsibility for their own health. Screening of existing staff helped to set an example and give staff with greater than 15 percent risk a chance to improve their quality of life, reduce their risk of a cardiovascular event and admission, and to set examples to their families and whānau around taking responsibility for their own health. A fitter workforce is a win-win for our staff and the organisation. • Initiating performance structured contracts with the Primary Health Organisations (PHOs) with support and performance-based funding components. Procare, for example, has used the support funding to

employ an additional nine nurses to support system changes and assist in the direct screening of patients, point-of-care (POC) testing and phlebotomy. • Employing three long-term condition coordinators to work within practices across the four PHOs to provide training in the use of screening tools for practice staff, and to support systems review where gaps are identified and assessments can be completed virtually. Although the national target is focused on screening assessments, the next step is to concentrate on managing those patients who have been identified as being at risk. We are working on long-term strategies around this including self management programmes tailored to different groups e.g. Healthy Village Action Zone to the Pacific Island community.

Auckland DHB was the first in the country to exceed the national target set by the Ministry of Health with 77 percent of our eligible Pacific population screened by May 2013. The percentage of eligible people screened has climbed from 54 % in December 2012 to 78% in June 2013.


healthier communities


Stopping smoking Smoking is the single most important cause of premature and preventable deaths in New Zealand, yet approximately 13 percent of people living in the Auckland DHB district smoke. Maori and Pacific people are more likely to smoke (38.4 percent and 23.1 percent respectively) and these population groups, along with pregnant women, are more likely to experience negative health impacts.


Smoking is a major public health problem. Tobacco smoking causes about 5000 deaths every year – with 350 of these from inhaling second-hand smoke, particularly children who die from Sudden Infant Death Syndrome (SIDS) and acute asthma attacks. The Ministry of Health has identified three smokefree targets relating to primary, secondary and maternity care that we have been working hard to achieve over the past year (see below).

• Primary Care: 90% of patients who smoke and are seen by a health practitioner in primary care are offered brief advice and support to quit smoking.

• Secondary Care: 95% of patients who smoke and are seen by a health practitioner in public hospitals are offered brief advice and support to quit smoking.

• Maternal Care: 90% of pregnant women who are identified as smokers at the time of booking with a Lead Maternity Carer are offered advice and support to quit smoking.

Primary care target To achieve the primary care target we employed two Smokefree Coordinators to work in the community – one is employed by Procare and the other by the National Hauora Coalition. These two coordinators, plus a Smokefree Liaison Coordinator employed by ADHB Smokefree Services, provide training for GP practice nurses so they can provide stop smoking support and promote the benefits of a smokefree lifestyle amongst their patients. In the 2012/2013 year only 37 percent of patients seen in primary care were offered advice to quit. The reason for the low result is not that brief advice and support to quit were not given, but that electronic records are unreliable. We are making changes to our approach for the coming year, including employing a full-time community liaison Stop Smoking Facilitator.


Secondary care target

Maternal care target

Our response to this target is based on the ABC (Ask, Brief Advice and Cessation) approach to encouraging patients who smoke to quit. All patients who present at an Auckland DHB facility are asked if they smoke when approached by health professionals new to them. By far the greatest majority have either never smoked or are ex-smokers. However, if the person is a current smoker they are given advice to stop smoking and offered support to do so either by way of referral to a stop smoking service or the supply of nicotine patches or similar therapy.

We have a team of three Smokefree Pregnancy Facilitators who visit clients in their homes and also make contact by phone call or text. Each facilitator is required to enrol 120 clients in each 12 month period and work with those enrolled clients to attain a four week and then 12 week quit period by following a tailored quit plan.

In the 2012/2013 year we have exceeded the target by five percent, with 95 percent of our patients who are seen in public hospitals receiving brief advice to quit smoking.

29-year-old mother Nicole Roberts-Tuahuru was approached by the Auckland DHB Smokefree Pregnancy Service while in hospital with toothache. The service provides smoking mothers with support and resources to fight tobacco addiction. Mrs Roberts-Tuahuru, a mother-of-six, has been completely smokefree since February 2012 and says the decision changed her life. Photo: Jason Oxenham / East & Bays Courier

Every month more than 95 percent of patients seen in our public hospitals receive advice to quit smoking.

In the 2012/2013 year we were five percent off meeting the target with 85 percent of Womenâ&#x20AC;&#x2122;s Health patients who smoke given brief advice to stop smoking. Of 170 patients referred to Auckland DHB Smokefree Pregnancy Services, 90 were enrolled into the quit smoking programme (52 percent).


Stopping smoking is the single best health decision that a tobacco smoker can make.



healthier communities


Home-based support Ageing in place The aim of the home-based support service (HBSS) is to enable older people to remain in their homes for longer periods, delaying or avoiding entry into residential care.


The HBSS model began its transformation in July 2009. Prior to this we ran a fee-for-service model with 10 providers. Inadequacy of evidence of client outcomes; poor data for service monitoring and planning, fragmented service provision and duplication of assessment processes led to the decision to review the model. With an ageing population, demand for services was predicted to rapidly increase beyond the capacity of the existing system. The purpose of the enhanced HBSS is to flexibly assist older people to achieve quality, cost-effective outcomes to enable them to live as independently as possible. The services are not limited to the purchase and delivery of domestic assistance or personal care, but are designed to achieve goal-based outcomes that are codesigned and owned by the client.

Our aim is to enable older people to remain living in their homes through the provision of timely, flexible and appropriate support services.

The objectives of the enhanced HBSS model are: • Streamlined access to services through a single point of entry. • The introduction of restorative community services that are strength-based and focus on the restoration or maintenance of independence. • The introduction and roll out of interRAI9 as a standardised uniform assessment tool for older people. • Development of packages of care to appropriately fund and incentivise providers in the coordination and delivery of care. A new service structure was developed comprising the Community Care Access Centre (CCAC), Specialist Services (Gerontology Services team) and four Community Provider Agencies. CCAC and the Specialist Service are Auckland DHB owned and operated while the community providers are contracted to deliver services.

9 An interRAI is a standardised, integrated comprehensive clinical assessment that assesses functional, physical and psychological domains.


Our achievements • 3850 clients receiving services in March 2013. Since the 2009/2010 year the average monthly client numbers have been increasing. In 2009/2010 the average monthly client number was 3490 clients which increased to 3657 in 2010/2011 and 3780 in 2011/2012. • All new clients are receiving an interRAI assessment. • 90 percent of support workers have achieved the level 2 or 3 support worker qualification. • All four community HBSS providers were audited for the first time in 2011/12. There were minimal corrective actions identified. Two providers each had one low risk issue identified.

In March 2013 we provided home-based support to 3850 clients, of which 76 percent were aged 85 plus. We are well on our way towards our goal of enabling older people to remain living in their homes.

• There has been a slowing in the cost of provision of home-based support services with an associated improvement in efficiency as volume and complexity increased over this time. A Balanced Scorecard for HBSS is being developed to enable comparisons across time, continuous improvement and benchmarking between providers. The Balanced Scorecard comprises four domains: client perspective; learning and growth perspective; business processes perspective; and financial perspective.


healthier communities


Big White Wall Providing support to people with a wide range of mental health and emotional problems is both expensive and complex when face-to-face direct contact is the only option. Providing support through web-based options has become increasingly attractive to clinicians and to people needing mental health support.


Auckland DHB is the first health organisation in New Zealand to roll-out a free online self-help service aimed at improving emotional wellbeing for people in need. Known as Big White Wall, the service is aimed at people aged 16-plus who are experiencing a mild-tomoderate mental health problem. It has helped 8500 people in the UK to date. In a nutshell, Big White Wall is a mental health equivalent of Facebook. Users can log on and access the service at any time, 24 hours-a-day. It allows users to engage with others and download resources and information, and offers peer support and further help where needed. The innovative service provides safe, anonymous support and operates on social media principles allowing online users to have control over how much

information they share and with whom. The site is moderated by mental health professionals who ensure the full engagement, safety and anonymity of members. This means that in comparison to other social media alternatives, it is relatively safe and information or advice is likely to be considered and sensible. Big White Wall fosters a supportive online environment focusing on recovery and wellness that allows people having a tough time to befriend others with common experiences without fear of stigma. The service provides an early intervention system as soon as an issue arises and can also be used as a support for people with severe mental illness to keep them out of hospital.


Some of the activities and services on Big White Wall Talkabouts: Members can talk to others in the Big White Wall community who share similar experiences. They can also engage with Wall Guides (counsellors), who are online at all times to ensure everyone is safe on Big White Wall. Distress tests: Members can take ‘distress tests’; find out more about topics ranging from anxiety and depression, to coping with redundancy and alcohol problems. They can also find out more to help them understand their worries and concerns and how to move forward. What’s on your mind? An illustration from the Big White Wall website that shows the range of online support provided.

One-in-four of us will experience anxiety, depression or other common mental health problems during our lives.

Creative art and writing therapies: It can sometimes be difficult putting feelings into words. Members can vent and express how they feel in images by making ‘Bricks’ on The Wall.

It can be hard to talk about worries or concerns, usually for fear of what others may think, so asking for help can be difficult. Big White Wall provides an option for people within the Auckland DHB area who may not yet feel ready to make a formal appointment with a mental health service. Big White Wall went live in November 2012 and to date 139 people have registered. The most recent statistics indicate that Auckland users are starting to post more and use the online information more than before, which suggests that, after an initial warming up period, people are starting to get used to the site and how it operates. Referrals from clinicians are still the most common reason for Auckland members to join Big White Wall.

One of the biggest advantages of Big White Wall is that it allows people to access services at whatever time and in whatever place they wish.


healthier communities


Dental clinics In New Zealand there has been no significant investment in oral health clinics since the 1960s. In the past, school dental clinics were owned and maintained by the education sector. However, the old clinics did not meet current standards for comfort and safety. This was one of the reasons behind the government’s decision in 2006 that all future investment in oral health clinics would be made by the health sector.


Following the change in policy approach, District Health Boards across New Zealand were required to submit business cases to support their request for Ministry of Health funding. Auckland DHB developed an Oral Health Business Plan in 2008 that proposed a complete overhaul of child and adolescent oral health services. The aim of the plan was to enhance and reconfigure the child and adolescent oral health service in the Auckland district. The old dental clinics have been replaced with modern, purpose-built clinics that have longer opening hours and stay open during school holidays, and new dental equipment has been purchased. The model of care has changed with a move to ‘four handed dentistry’ meaning that more dental therapists and dental assistants are being employed. All of this will result in reduced inequalities, improved access to services and better oral health outcomes for children and adolescents.

In mid-2010 we began the building phase of the plan, which involved building or refurbishing 14 new dental clinics with new equipment, employing more staff and purchasing six specialised mobile dental vans. The new purpose-built and mobile dental clinics offer a more comfortable experience and better service to young patients with their modern facilities and faster diagnostic equipment. Each clinic focuses on prevention rather than “drilling and filling”, and provides dental treatment to its neighbouring schools and wider community. The last of the 14 new clinics opened at the Greenlane Clinical Centre in April 2013. This investment ensures ongoing provision of oral health services for our population. Not only does it increase access, it also provides better healthcare and oral health outcomes.

Nearly $111 million of capital expenditure and more than $3 million of annual operational funding was made available for the reconfiguration of child and adolescent oral health services.


Pre-school enrolment The number of enrolments of preschool children to the dental service has steadily increased over the last five years, with the target for 2013 set at 76 percent.

Percentage of Auckland DHB preschoolers enrolled in Auckland Regional Dental Service 80

% enrolled





2007 Maori

Dental Therapist Alex Samotol with a young patient at the Greenlane childrenâ&#x20AC;&#x2122;s community dental clinic.

The Auckland Regional Dental Service sees on average about 80,000 children annually in the Auckland DHB area. At a regional level, including Auckland, Waitemata and Counties Manukau DHBs, the figure increases to more than 300,000 children.




PaciďŹ c









Creating better value for you As guardians of the health funding for our community we are focused on finding innovative ways to deliver healthcare. Itâ&#x20AC;&#x2122;s about being more efficient so we can continue to provide high-quality care to our patients and community now and into the future. This chapter identifies some of the projects within Concord, a clinically-led quality programme.

Concord leaders Dr Kerry Gunn and Dr Andrew Old.


better value for you


Introduction to Concord Concord is a clinically-led, quality improvement programme aimed at finding ways to deliver the right amount of care across Auckland DHB. It’s about working together to provide the right care, at the right time, in the right way.


The goals of the Concord programme are to generate and sustain innovative ways of delivering the right amount of care by working with clinical staff, encouraging appropriate use of limited resources and partnering with patients and their families.

A widespread and continuous communication campaign, including story-telling using patient experiences, is developed to create and sustain awareness of the programme and help ensure the project benefits are realised.

Everyone at Auckland DHB is encouraged to submit ideas to improve patient experience and reduce waste in the healthcare system. This could be waste in time, money or re-work that impacts on patient safety, patient experience or the ability of staff to do their job effectively. Everyone is encouraged to get actively involved in the programme, and those who submit ideas that develop into projects remain involved in the implementation of solutions.

We track a range of programme indicators including the number of ideas received and benefits realised. The number of ideas submitted by staff continues to grow with almost 500 now received and reviewed.

The key to the success of Concord is the partnership of clinical leaders and quality improvement experts. This is borne out in the active participation of the Clinical Steering Group, chaired by the Chief Medical Officer. No project is implemented without a clinical champion and the project teams include key clinical stakeholders. Project improvements and solutions are owned by the clinical services who take responsibility for the sustained improvement.

Some of the Concord projects include: • Advance Care Planning – helping people think about, talk about and plan for end of life care (refer page 28) • Reducing unnecessary blood test requests (refer page 58) • Choosing Wisely – a portfolio of improvement projects centred around the premise of effective care based on sound clinical evidence (refer page 60) • Reducing waste associated with the oversupply of drugs (refer page 62) • Blood is a Gift – almost 9000 fewer blood units transfused.

The key to the success of Concord is the partnership of

clinical leaders and quality improvement experts.


Concord’s work was recognised in 2012 when the ‘Blood is a Gift’ project won the ‘improving public value’ section of the IPANZ public sector excellence awards.

Our projects have contributed to better use of resources. For example, we have:

We are contributing to the performance improvement culture by:

• used 4000 fewer Sharps Bins to discard needles and other sharp items

• developing educational resources (including websites and toolkits)

• changed our lab forms and generated 135,000 fewer lab blood tests orders • improved blood management and transfused 5000 fewer blood products • reduced pharmacy stock waste by 32% by changing the dispensing practices and processes • ordered 6600 fewer mid-stream urine tests • saved 3500 units of red blood cells, almost 1400 fresh frozen plasma, 20,000 hours of patients’ time and 3700 hours of nursing time – resulting in more than $2.7m in savings thus far. The Concord programme was presented at the 2013 International Forum on Quality and Safety in Healthcare conference in London.

• presenting at Grand Rounds10 and training staff • presenting at local and international conferences • designing and running marketing campaigns to change behaviour • collaborating regionally and nationally • capturing many patient stories in order to drive a culture of delivering the right amount of care.

10 Grand rounds are a teaching tool where a medical problem and treatment of a particular patient is presented to an audience consisting of doctors, residents and medical students.


better value for you


Reducing unnecessary blood test requests Simplifying the laboratory test ordering form resulted in a 50 percent reduction in ordering for urea testing, and similar reductions for other tests, resulting in total savings of more than $300,000 across an 18 month period.


The standard form used for requesting blood tests had 72 tick boxes for different types of tests. Some of these tests were similar and some not very useful. Busy doctors would sometimes tick many more than were actually needed. This meant that not only were we wasting precious health dollars carrying out unnecessary tests, but doctors had to read through a lot of results and information, which had the potential clinical risk of missing the key test results. The project team carried out in-depth clinical consultation, which identified that urea is seldom a useful test (with some exceptions) yet 57 percent of inpatients were having urea tests. The project team also identified other tests that were being checked automatically. The solution was to design a new form, removing some of the tick boxes and regrouping some of the tests while retaining space to request any of the tests that were no longer listed. The new form was initially piloted in four wards to ensure the tests left on the list were the ones most needed. The pilot saw a substantial reduction in test orders and following a positive response from those involved, the form was rolled out across a further 170 Auckland DHB locations.

Dr James Davidson, a Chemical Pathologist who was involved in the project, said, “The new form has struck a balance in keeping tick boxes, which are easier for doctors to fill in and easier for lab staff to identify, whilst reducing the number of unnecessary tests carried out.” Within 18 months the number of urea tests reduced by 50 percent and other tests also saw substantial reductions. This project has not only improved patient safety and saved clinicians’ time by reducing the number of test reports they need to read, it also saved more than $300,000 in the first 18 months.


New Laboratory Blood Request form The new form has simplified test ordering and reduced the number of unnecessary tests carried out.

Doing the right testing to determine a diagnosis or inform a clinical decision is important to avoid money being wasted on tests that are never looked at, but also to avoid unnecessary patient anxiety from getting diagnosed with conditions that aren’t actually a problem for them at all.

Impact of the laboratory order form project The project significantly reduced the number of Urea, AST, calcium, magnesium and phosphate tests being ordered. Monthly mean Pre-project


Percentage reduction






















better value for you


Choosing Wisely Choosing Wisely is a portfolio of clinically-led improvement projects that implement effective care practices based on sound clinical evidence. We want to provide our patients with the right amount of care and avoid wasting time, resources and causing patient harm by performing unnecessary diagnostics tests or treatment.


Costs for Auckland DHB healthcare services have risen faster than patient volumes and have become unsustainable. Cliniciansâ&#x20AC;&#x2122; decisions, whether these relate to ordering tests, deciding how best to treat a medical problem, or making sure patients remain healthy after treatment, drive a lot of these costs. While many of these costs are justifiable, some are not. For instance, when there is no clinical evidence that a test or treatment works, when test results are not used in clinical decision making, when there are better alternatives, or when the medical effort does not help the patient (and their family) as they see it. Not only are these activities wasteful, as they are not adding value to the health of the patient, they are also potentially harmful as every medical activity carries a risk.

The Choosing Wisely programme was born out of a desire to influence clinical choices and ensure the resulting care provided is effective. The ultimate longterm goal is to make the Auckland DHB service sustainable so we can treat more patients in the future. The two main ways of doing this are through the adoption of evidence-based practice and more actively involving patients in choices related to their care. Typically, a project involves the definition of a problem (i.e. unnecessary test ordered); the review of relevant evidence; the definition of a standard care pathway, guideline and protocol; building consensus with key stakeholders; implementing the pathway; and tracking pathway performance.


The Choosing Wisely portfolio now has 24 projects, five of which have been completed. Total annual savings for the system are estimated to be between $2-3 million. It is expected that the number of projects will grow significantly during the next year following further engagement with clinical services and a review of overseas evidence.



Reduction in Clozapine level tests This graph demonstrates the change in the number of Clozapine tests requested following the implementation of the project.


40% reduction in Clozapine level test requests

1400 1200 1000 800 600 400

CLOZ test completed

Not completed for other reason

















Test declined

Providing only effective care ensures we utilise scarce health dollars in the best way, future proofing our health system for the

next patients.

Critical success factors include ensuring there is a strong clinical lead, compelling evidence, and a clear understanding of how and when the choices are made. Following an organisation-wide call for suggestions the programme started with 38 ideas, which were evaluated based on their potential, their ease of implementation and organisational readiness. The programme is now also being expanded to include a specific set of projects to reduce unnecessary ! The project team outpatient follow-ups. developed a toolkit aimed at assisting clinicians to consider their follow-up decisions and implement alternatives to clinic follow-ups, such as phone followups or virtual follow-ups. 11 ESR is the erythrocyte sedimentation rate. 12 CRP stands for C-Reactive Protein. 13 Bartholin abscess is the build-up of pus that forms a lump in one of the Bartholin’s glands, which are located on each side of the vaginal opening.

Project successes • 40 percent reduction in Clozapine level tests (used to control schizophrenia), which are routinely requested for monitoring toxicity and adherence to prescription. The Choosing Wisely programme identified them as being overrequested and as a result, requests have been reduced. • 87 percent of ESR11 tests are ordered in conjunction with a CRP12 test. Both test for inflammatory reactions and usually only one is needed. The Choosing Wisely programme identified the doubleup and ran an awareness campaign across the hospital, resulting in fewer ESR and CRP tests. • Bartholin abscess13 surgeries currently keep 54 women in hospital overnight following general anaesthesia, whereas these can be done in 15 minutes in a treatment room under local anaesthetic. The Choosing Wisely programme introduced a new procedure room intervention which meant that the patient is treated without general anaesthetic and is therefore able to go home quicker.


better value for you


Reducing waste associated with the oversupply of drugs The issue of excessive returns coming back to the pharmacy from the inpatient wards was identified by the pharmacy team as an issue in 2012. A project team was set up to assess and evaluate the current amount of dispensed medicines at Auckland City Hospital that are being returned to the inpatient pharmacy, and to adjust standard operating procedures around our issuing and returns processes to reduce medicine wastage.


The team identified four primary drivers to help reduce returns coming into the wards, as listed below: • ensuring the correct amount of stock was held on the wards • ensuring the right amount was being dispensed • ensuring the medicines were sent to the correct ward the first time • creating more awareness around the cost of medication. It was also identified that reducing returns would reduce wastage due to expired stock and the time taken to process returns by pharmacy staff. A pilot study was set up with seven wards in the first quarter of 2013 that implemented the following changes: • revised the average length of days being used for dispensing in the wards • minimised the proportion of high cost medication on the imprest lists14 and made them dispensing only, thereby ensuring they are only called for when required. 14 An imprest list refers to a standard list of drugs readily available in the drug rooms of the ward, e.g. paracetamol

• set minimum and maximum levels of stock held on wards and put into place auto-replenishment for those medicines that are supplied more frequently. The pilot is currently in its second phase and the changes are now being implemented across Auckland City Hospital. Nineteen wards are working within the revised average length of days used for dispensing and the autoreplenishment process is currently being piloted in the medicine room of the theatres on level eight of the hospital, ahead of a wider rollout.

In the first five months of the pilot study, the project has already yielded more than $200,000 in savings.



better value for you


Blood is a Gift The ‘Blood is a Gift’ initiative is aimed at introducing and embedding blood management principles and practice at Auckland DHB. The initiative has multiple sub-projects that look at providing improved quality of care to the population with better utilisation of existing funding.


Patient blood management is an evidence-based, multidisciplinary process that is designed to promote the optimal use of blood products and components throughout the hospital. Blood is a liquid transplant and whilst blood products today are the safest in history, transfusions are not risk free and cause some degree of harm in every patient due to the physical properties of stored blood and because of impairments in immune system functions. The goal of ‘Blood is a Gift’ is to ensure the safe and efficient use of the many resources involved in the complex process of blood component therapy. These resources are not limited to just blood products and also include nursing time, supplies, laboratory tests, pharmaceuticals, and patients’ length of stay – all of which impact on healthcare dollars. The initiative started under the banner of the project called “Why use two when one will do” which looked at moving to a single unit transfusion. Historically clinicians had been transfusing two units of red blood cells as standard practice while international best practice had moved away from this protocol to transfusing only one unit and then reevaluating the need for the second unit. The solutions included new protocols and

medical algorithms to support medical practice and transfusion prescription based on medical evidence. This was done alongside an education and awareness campaign led by Dr Kerry Gunn, chairperson of the Transfusion Committee and a specialist anaesthetist. In addition to the above project, there are other ongoing initiatives, including: • standardising appropriate physiological thresholds for transfusions • introducing an e-ordering system which will influence prescription and transfusion practice • dispensing iron supplements through intravenous methods to reduce transfusion of red blood cell units to highly anaemic patients • reducing wastage of red blood cell units due to incorrect storage in the operational areas within the hospital.

The initiative started under a project called “Why use two when one will do”.


Since October 2010 we have made the following savings: • almost 9000 units of red blood cells • more than 3000 units of fresh frozen plasma • more than 48,000 hours of patients’ time • 9000 hours of nursing time These savings have resulted in financial benefits of $5.8m so far.





The best team to deliver quality Our staff are vital to the effective and efficient operation of our organisation. They also help to define the experience of our patients and the community we serve. At Auckland District Health Board staff are listened to, have the skills and knowledge to do their jobs and know their role in the pursuit of healthcare excellence. This chapter examines two people-based initiatives: Green Belt training and Reducing Time to Care. The first trains staff and helps them to identify opportunities for process improvement, and the second creates efficiencies in the workplace freeing up time for staff to provide more direct patient care.

Dr Michael Shepherd, Clinical Director, Paediatric Emergency Medicine.


engaged workforce


Green Belt training The Auckland DHB recognises that its staff on the front-line are best placed to solve many of the organisation’s current challenges. With this in mind, it has created a programme to help staff develop quality improvement and change management skills. The programme, known as Green Belt Training, involves a combination of classroom teaching combined with on-the-job project work.


The Green Belt programme was developed in-house and is facilitated by the Auckland DHB Performance Improvement Team. It focuses on technical improvement tools and leadership skills, a crucial combination for any successful change project. Using a blend of Lean Six Sigma and other quality improvement tools, together with change management and project management tools, the programme provides participants with a handson learning experience. Participants, supported by a mentor and project teams, complete two improvement projects as part of the one-year Green Belt programme and are expected to go on to complete further improvement projects in their respective work areas. The projects that have been identified by Green Belt participants are wide ranging. Some have helped the DHB to achieve specific improvement targets, such as reducing length of stay in ED, while others have focused on improvement opportunities across the organisation. Examples of Green Belt projects can be seen on the next page.

Green Belt training has given me the skills to lead performance improvement in a systematic way that can show accountability and tracking. It is one of the ways we can make sure the right patient receives the right amount of care

in the right way.

– Gretchen Thomas, Clinical Effectiveness Advisor

69 A selection of completed quality improvement projects following Green Belt training Delays to discharge – Ward 42R

Emergency Medicine referral time

General Medicine rosters

Whiteboard discharge date accuracy

Delays to discharge – Ward 68

Estimated discharge date accuracy

Ready-to-go meeting effectiveness

Hip fracture time to theatre

General Surgery acute patient sign-on time

Improved nursing care plans

Paediatric Orthopaedics – estimated discharge

Discharge summary wait time

Cardiology: angiogram wait time

Bed request acknowledgement time

Weekend discharging

General Medicine AED to ward transfer times

Pharmacy NHI numbers

Reduction in Radiology consumer spend

Radiation Therapy 28 day project

HR reporting accuracy

Timely coding of inpatient events

OPH pain management

Reducing blood product wastage

Timesheet accuracy

Ophthalmology demand management

Chemotherapy 28 day treatment

Acute mental heath long stays

Maternity diabetes – clinic wait times

Renal clinic time to admit

Radiology theatre cancellations

Three months ago I was asked how I could save money on our inventory expenditure and the first thing that came to my mind was “how do I do this?” and “where do I start?”. The Green Belt training has given me the tools to get a more robust process going that will be sustainable long term. Along the way, the benefits to the department and organisation will be reduced cost and better use of my time.

– clivena Ngatai, Charge Nurse Manager, Radiology

Approximately 100 staff have completed Green Belt training since its inception in March 2010, with a further 300 attending a two-day Improvement Fundamentals course.


engaged workforce


Releasing Time to Care Releasing Time to Care (RTC) is a programme developed by the National Health Service in the UK. Its purpose is to assist ward teams to review the way in which they undertake activities with the goal of removing waste and freeing up time to provide more direct patient care.



Accelerated RTC pilot results Direct care time = 54% (38% improvement)

7 Process Modules delivered

Patient satisfaction = 91 % 3 Foundation Modules delivered Staff satisfaction = 84 %

Reduction in pressure injuries = 0 in 6 months Reduction in length of stay >0.8 days Sustained smoking cessation >95% Sustained Acute Patient Flow >95%

It really has increased the amount of time we can

spend with the patients.

– Staff Member

Auckland DHB embarked on a journey to implement RTC in 2009 and has implemented it in 33 wards. Following a recent review, a new accelerated approach has been piloted in one ward with positive results. Plans are now in place to extend this approach to all wards in the next two years. Releasing Time to Care is a modular programme, which means wards that participate can choose the sequence best suited to their situation. Ward 72 is the main Respiratory ward and was chosen to trial an accelerated version of RTC15, commencing in July

Increasing direct care time Implementing the Releasing Time to Care programme in Ward 72 has increased the amount of direct care time staff have with patients by more than 38 percent. Direct Care Time (Ward 72)

Direct Care Time (organisation wide)

February 2012




May 2013




Foundation Modules Knowing How We are Doing Well Organised Ward Patient status at a glance

15 RTC is typically rolled out over two or more years with modules taking between 3-6 months to complete. The accelerated programme allocates a month per module and is completed within a year.

2012. Resource from the Performance Improvement team was allocated to work with the ward on a module each month until completion in May 2013. The ward implemented seven process modules and extended the three foundation modules already initiated, as below. To kick-start each module, the team analysed data on adverse events and patient complaints, carried outpatient and staff interviews, and observed existing processes. This information helped the team to better understand the current state and the areas in need of improvement, and was used to shape the new processes. Process Modules Shift Handover Meals Patient Observations Patient Hygiene Medicines Admissions and Planned Discharges Ward Rounds



A lack of coordination, duplication, unclear processes and poor layout had led to a high level of non-value adding time on the wards. Releasing Time to Care has provided an approach to help teams streamline processes, improve layouts and coordinate care with the aim of ensuring nurses spend more time caring for their patients.

Accelerated pilot outcomes Knowing how we are doing • Engaging the entire ward team through the development of a common vision. • Implementing daily ward meetings to review and address performance, issues and risks, and celebrate success. This has been key to improving staff engagement as well as improving performance against key targets including smoking cessation, acute patient flow, and increasing awareness of falls and pressure injuries. • Improved performance against key targets including smoking cessation, Acute Patient Flow and increasing awareness of falls and pressure injuries. • Improved cross- team communication through the introduction of the “Patient Status at a Glance” electronic whiteboards, the implementation of rapid rounds and “Staff Status at a Glance” boards, which have contributed to a reduction in the length of stay.

• Improved patient and family involvement and staff communication through the use of patient status boards at the bedside. Well organised ward • Significant improvement in the appearance of ward 72 and improved accessibility to items through decluttering and establishing a place for everything. • Reduced stock holding which resulted in less out-of-date stock and better utilisation of space. • Nursing time saved by relocating equipment to point-of-use locations. • Significant reductions in wasted time through the improved organisation and layout in medication rooms. Shift handover • Increased patient involvement and awareness through bedside handover. • Improved information transfer. • Reduction in time spent away from the patient.

Meals • Improved focus on patient preparation resulting in an improved patient experience and better nutrition. • Nurses now assist patients to complete meal cards ensuring sufficient food is ordered and fewer meal call-backs are required. • Meal preparation bells have been installed to remind nurses it is time to ensure patients are sitting up with hands washed ready for meal time. Patient observations • Significant improvement in direct care time through the better location of observation equipment at the point-of-use (within four bedded rooms and outside single rooms) and a wider variety of equipment on observation trolleys. Patient hygiene • Improved patient hygiene by providing hygiene packs (toothbrush, toothpaste, shampoo, and comb) to new admissions in need and those unable to provide their own.


Admissions and planned discharges • Development of a patient welcome pack including information on ward processes, the ward team and maps plus brochures on the transition lounge16, falls, pressure injuries, patient rights etc. • Improved communication, awareness and education for patients through improved conversations at ward rounds. Ward rounds • Utilising a laptop during ward rounds to check results and order tests at the bedside ensures the medical team does not have to leave the bedside. • Junior doctors now ‘read back’ the patient plan to ensure accuracy and clarity for patient and staff. • Increased nursing involvement in ward rounds to improve continuity of information to patients.

16 The area where patients wait to be picked up once they have been discharged from hospital.





Our future focus Organisations like ours donâ&#x20AC;&#x2122;t stand still. New research will continue to identify better healthcare options and improvements in the way we serve our community. We are committed to continuous improvement, which is why we introduced a new performance framework in 2010. The framework, Healthcare Excellence, helps us to build on what already works well and identify and deliver the best care for our patients into the future. This chapter looks at five areas of focus in the coming financial year.

Te Whetu Tawera staff enjoying the new mural in the outdoor area of the Intensive Care Unit.


future focus


Safer hospitals Keeping our patients safe is a key priority at Auckland DHB and the responsibility of everyone across the organisation. We aim to provide the best and safest care possible. We like to think of it as the patient comes first, the healthcare equivalent of “the customer is always right”. We are working with regional and national partners to ensure our hospitals are safer now and into the future.


At Auckland DHB we aim to eliminate avoidable harm and ensure our patients experience the safest possible care. Patient safety is important on many levels: it saves lives; reduces re-admissions; avoids complications, pain and suffering; provides a better experience for patients (getting it right the first time means they can get back to their normal lives sooner); and it saves money. Auckland DHB is committed to two significant patient safety campaigns – one regional and the other nationwide. Regionally, we are a member of First, Do No Harm (FDNH) a campaign that aims to develop a patient safety culture across the Auckland region. On a national level we are committed to Open for better care, the national patient safety campaign led by the Health Quality & Safety Commission. When you look at the numbers around patient harm, it’s easy to see why changes to patient safety must be a priority. • A 1998 New Zealand study of hospital discharges found that 12.9 percent of our patients had adverse events, 15 percent of those were permanent or fatal and 33 percent were significantly avoidable. • Avoidable serious adverse events translated to around 276,000 additional

bed days. At an average cost of $13,000 per adverse event, the cost of preventable adverse events is estimated to be $573 million per annum. Source: First, Do No Harm website • In the two years from 2010 to 2012, 170 people fell while in public hospital care and broke their hips. Among this group, 22 more people died than we would otherwise expect. • Up to 10 percent of people admitted to hospital acquire an infection, and many of these are likely to remain in hospital longer and have a longer recovery time. • Medication errors made up five percent of serious harm reported by DHBs in 2011/12. • Between 2005 and 2010, ACC accepted a total of 205 claims for retained instruments or wrong site surgery. Source: Open for better care website FDNH has brought together the Northern region’s four district health boards (Northland, Auckland, Waitemata and Counties). For the first time, we are working together with primary care and age-related residential care to deliver a new, system-wide focus on patient safety.


Working regionally means there’s increased opportunity to share resources and data, and it means patient safety is a priority regardless of the setting (e.g. hospital or residential care). The FDNH campaign has set specific targets for reducing patient falls, pressure injuries and central line infections (CLAB). The campaign is led by improvement science and data. It encourages members to collect and share data and it educates them on how to analyse it – ‘crunching the numbers’ helps to identify the issues and determine the solutions. FDNH works alongside the national patient safety campaign, Open for better care, which is led by the Health Quality & Safety Commission. The campaign was launched in May 2013 and focuses on reducing harm in the areas of: falls, surgery, healthcare associated infections and medications, with falls the first area of focus. The aim of the campaign is to: Enable the health and disability sector to ensure everyone is doing the right thing, and doing it right, first time.

Patient safety has benefits for staff too While patients are at the heart of patient safety, there are benefits for staff too. Improving processes that lead to improved patient safety can reduce wasted time, allowing staff more direct patient care. Anyone who’s worked in the healthcare sector will know it’s more satisfying to see a good patient outcome. Staff enjoy the reward of seeing happy, satisfied patients and families leaving the hospital. And the dollar savings can be redistributed to other clinical areas of importance. Keeping our patients safe extends to a broader goal of safer hospitals in general. It’s about taking a different view – looking for opportunities to improve, and asking the question – can we do this better and how? The healthcare sector can never stand still – in fact, it would go backwards if we didn’t continually maintain our focus on patient safety.

Another old adage springs to mind – if you’re going to do it, do it right. Safer hospitals means doing things right the first time – which has positive outcomes for our patients.

overseas is gaining momentum here – the framework is about staff, patients and other stakeholders working together to achieve the desired outcome. It’s about giving our patients a voice.

Increasing patient involvement in their care and the approaches we take is another aspect of the safer hospital vision – like anything, the level of commitment increases with the level of involvement. We can learn from our patients and appreciate their input. The co-design model prevalent

However, there’s always more to do, which is why patient safety is an ongoing goal. It’s something that filters through to everyone who works at Auckland DHB. Creating safer hospitals is a continuous journey and one that we’re proud to be taking with our patients.

Auckland DHB is proud of its safety achievements in the past year: • We now assess 91 percent of hospital patients for falling risk (up from <75 percent) • We’ve classified pressure injuries as “never events” and have had only one serious pressure injury (grade 3 or 5) since July 2012 • Three of our intensive care units exceeded 100 days without a central line-associated bloodstream (CLAB) infection • Ninety-nine percent of patients now have crucial checks on their identify and intended surgical procedure on entering the operating theatre • The highest level of hand hygiene compliance in the country.


future focus


Medication safety The Pharmacy department at Auckland City Hospital is always looking for opportunities to improve quality of care and reduce cost. Projects for 2013/14 include medicines reconciliation at admission and electronic medicines management (prescribing and administration). However, Pharmacy doesn’t want to stop there and has identified a range of other initiatives for the coming financial years. This section outlines some of Pharmacy’s future-focused initiatives.


Give pharmacists greater visibility on the wards

Undertake regular audits on the quality of prescribing

• We want to look at ways of better utilising the strengths of our staff and to have greater visibility of pharmacists and pharmacy technicians on the wards, interacting with patients and healthcare professionals to improve outcomes.

• Following the introduction of the National Medication Chart we have identified the need for a regular audit that provides feedback tailored to individual consultant teams on how well their team is doing in regard to the quality of their prescribing. We also plan to combine this with feedback from pharmacist interventions related to other aspects of medicine use (rather than just the national medication chart).


• More than $45 million spent on medicines across Auckland City Hospital and Starship in financial year 11/12 • Only 58% of urgent prescriptions were turned around in 40 minutes or less across 11/12. The target is 90% • CIVAS17 savings for 2012/13 are already $250,000 above what was projected 17 Central Intravenous Additive Service (CIVAS )



Recruit a new antimicrobial18 stewardship pharmacist position

More than $45 million is spent on medicines within the hospital each year with around 50 percent of this spend on just 50 drugs. We are looking for ways to reduce this spend and utilise the savings to further improve patient care and treatment outcomes.

• We aim to recruit to a new antimicrobial stewardship pharmacist position in mid 2013/14. This role will support the antimicrobial stewardship committee and in particular identify opportunities for better quality prescribing of antimicrobials. The consequences of this will be reduced costs and also improving antimicrobial resistance (from inappropriate therapy choices). It is projected that this post will realise $367,000 net savings in the first year from more appropriate use of antimicrobials. As well as financial savings, this will also contribute to reducing antimicrobial resistance and improving patient outcomes. Launch the Medication Safety Moodle – an online education tool for nursing staff • 2013/14 will see the launch of the Medication Safety Moodle. This is an online education and training package targeted at nursing staff. 18 Antimicrobial medicines are grouped according to the microorganisms they act primarily against. For example, antibacterials (commonly known as antibiotics) are used against bacteria and antifungals are used against fungi. 19 Refer footnote 14 on page 62.

It will focus on key elements of safe medication use including: the ‘five rights’, allergies and Adverse Drug Reactions, reporting errors, documentation, and smart infusion pumps. We hope to prove that this is an essential education package for nurses and that it needs to be one of the mandatory courses for all nursing staff to complete. Investigate the benefits of robotics and using a dispensing robot • The Pharmacy at Auckland City Hospital has a particular interest in technology and informatics. We are currently investigating the benefits of robotics. Employing a dispensing robot for inpatient and imprest19 dispensing is likely to have a range of benefits, including a reduction in the opportunity for error, improved stock control and decreased processing time, and will enable the Pharmacy team to operate more closely with patients and staff on the wards. It will also enable the team to participate in discharge planning and medication counselling with opportunities to reduce readmissions due to medication issues.

Publish a revised policy on patient selfmedicating • In 2013/14 we plan to publish a revised policy on patients selfmedicating on the wards. This policy will be the basis for ensuring that wards have clear guidance on assessing patients’ suitability for being responsible for taking their medicines on the ward. Not only will this empower patients and more closely involve them with the recovery process, but it will also enable nursing and pharmacy staff to have a more supervisory role than they currently have with the traditional inpatient medicine administration process. Review core safe administration processes and provide senior management with recommendations • Significant work has been done during 2012/13 utilising a multidisciplinary team to review some of the core processes when administering medicines. This includes a review of the independent double-checking process and will describe all the key steps that staff should follow when administering medicines to maximise the safety of the patient. The recommendations from this group will be made available to senior management for endorsement towards the end of 2013.


Graph showing the Concord CIVAS project savings made to date (vs. projected) $60,000 $50,000

The Concord project that created a Central Intravenous Additive Service (CIVAS) within Pharmacy has realised savings of $250,000 above those projected for 2012/2013. This is just the tip of the iceberg both in terms of financial savings and also in releasing nursing time to care for patients rather than preparing medicines for use.

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Graph showing percentage of urgent items dispensed in 40 minutes or less 100 90 80 70 60 50

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% of urgents dispensed in 40 minutes or less


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While the Pharmacy team has shown excellent cost savings, there are still some core pharmacy functions that relate to the safe and quality use of medicines that require attention. One example is our ability to dispense urgent requests for prescriptions for inpatients within a suitable timeframe. The target is for 90 percent of these items to be processed by the dispensary in 40 minutes or less. We have rarely achieved that target and from July 2011 until now our average is 58 percent. The department is actively investigating the reasons for this and will review our processes in order to improve results.

Better use of medicines, better use of staff, better patient outcomes with potential for a reduced overall cost.

Did you know? In the 2011/2012 year the Auckland DHB pharmacy: • issued more than 200,000 imprest items • dispensed almost 146,000 individual items for specific inpatients • issued almost 10,000 urgent scripts and more than 13,000 urgent items • dispensed more than 2700 clinical trial items.


future focus


Surgical site infection surveillance programme Up to 10 percent of patients admitted to our hospital will develop an infection during their stay, and of these a fifth will be surgical site infections (SSI). Patients who develop a SSI, when compared to those who do not, have a twofold to 11-fold higher risk of death. A significant proportion of these infections are preventable, which is why we are focused on reducing the number of infections and SSIs our patients sustain during their stays.


Surgical site infections are expensive – they prolong hospital stays and require readmission to hospital for further interventions. While the cost to a hospital can be estimated from the additional length of stay, the cost to the patient and their family/whānau is often not known. For example, there may be delayed return to activities of daily living and to the workforce, placing the family under considerable financial pressure.

The programme’s key objectives are to:

Surgical site infection surveillance has been undertaken at Auckland DHB for a number of years now. However, while the SSI rates have been reported to the relevant services, minimal improvement activities have occurred in response to these results.

The programme will be implemented using a staged approach, with orthopaedic operations for hip and knee replacement the first procedures to be assessed.

In 2012 Auckland and Canterbury DHBs agreed to be the joint Lead Agency for the delivery of a National Surgical Site Infection Surveillance Programme in collaboration with the Health Quality & Safety Commission. The overarching objective of this programme is to improve the quality of patient safety and care.

• facilitate the collection of surveillance data to assess the incidence of SSI in New Zealand hospitals • analyse and report trends in SSI rates in New Zealand hospitals • facilitate local analysis of data and, where possible, reduce SSI rates and improve patient outcomes.

Beginning in February 2013, Auckland DHB and seven other DHBs began a trial of a web-based entry data collection system. From March, data has been collected on all hip and knee joint replacement procedures undertaken at each DHB with the initial data analysis undertaken in June.


The aim is to examine the data to identify whether adherence to best practice before, during and after surgery is being maintained. The data will identify those practices that are shown to be less than optimal and where improvement activities are required, for example the timing of the surgical antibiotic and the dose of the antibiotic given.

While it remains early days for this programme, we have already made changes to our current practice which we anticipate will reduce infection rates and improve outcomes for our patients.

Surgical site infections are expensive – they prolong hospital stays and require readmission to hospital for further interventions. While the cost to a hospital can be estimated from the additional length of stay, the cost to the patient and their family/whānau is often not known.


future focus


VTE assessment Recent complaints to the Health and Disability Commission (HDC) about hospital-acquired Venous Thromboembolism (VTE) events has led to the establishment of a project team to review the situation at Auckland DHB.


Research suggests there are approximately 1500 hospital-associated VTE events in New Zealand every year. Given that Auckland DHB has approximately 10 percent of the New Zealand population, approximately 150 of these would take place at Auckland City Hospital. Against this background, a project team has been set up to identify ways in which we can reduce the number of VTE events.

The most common clinical presentation in the spectrum of VTE is as a deep venous thrombosis (DVT), but it may present as a pulmonary embolism (PE). A PE is a blockage of the main artery of the lung or one of its branches by a substance that has travelled from elsewhere in the body through the bloodstream (embolism).  The risk of developing VTE increases tenfold in patients admitted to hospital versus non-hospitalised persons, with contributing factors being general ill health, malignancy20, reduced mobility and poor fluid intake, as well as surgical procedures, particularly orthopaedic and other high-risk surgeries. The HDC investigation into VTE events identified a lack of consistency of assessment and interventions nationwide. The Commission has now acknowledged VTE prevention as a key patient safety initiative, given the strong clinical evidence associated with preventing harm to patients. While New Zealand has no equivalent data, it is useful to look to Australia where it is estimated to cost $10,000 per VTE event. If we assume similar costs in New Zealand, then this equates to about $1.5 million per annum for Auckland DHB. 20 Malignancy is the tendency of a medical condition, especially tumors, to become progressively worse and to potentially result in death.


Number of VTE events per 1000 discharges

Our response is to form a project team to investigate ways in which we can reduce the number of VTE events, which will deliver the double benefit of reducing harm to patients while at the same time reducing cost.

This graph shows the number of VTE events that occur within Auckland City Hospital per 1000 procedures where surgery occurred or the patient was given anaesthetic. The rate for this appears to be variable but it is within statistical control (within the bounds of the red lines). Statistical control implies no outside factors influencing the results.

VTE Rate per 1000 Surgical or Anaesthetic Procedures

It remains early days but the project team’s initial findings are that while VTE risk could be reduced or eliminated through the use of interventions such as compression stockings and anticoagulants, it could also lead to greater risks such as pressure injuries and excess bleeding. The current thinking is that VTE prevention has to be done on a patient-by-patient basis and is about balancing all of a patient’s risks, not eliminating them.

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Next steps are to develop and test a VTE assessment form with selected wards, before implementing it hospitalwide. The results of the form would be monitored for three to six months to enable us to determine whether wider intervention is required.

The risk of developing VTE increases tenfold in patients admitted to hospital versus nonhospitalised persons.


future focus


Hydration and nutrition Malnutrition exists in our patient hospital population and it needs attention. Malnutrition increases length of stay, can cause other complications and delay discharge. It is imperative that all patients in our care are routinely assessed and monitored for their nutrition and hydration status. To do this effectively, we need to raise awareness among management and clinical teams of the importance of appropriate nutritional care and intervention for our patients.


Put simply, nutritional status is associated with better patient outcomes. Hospital malnutrition is a well recognised and world-wide phenomenon that has clinical and financial implications. It complicates illness, delays recovery, prolongs hospitalisation and increases the need for further interventions and high-dependency nursing care. Malnutrition is also associated with apathy and depression which can impact on recovery. A vital part of addressing and treating malnutrition is its early identification. Nutritional screening needs to be mandatory for all patients admitted to hospital wards. Identification of malnourished patients and those at risk of developing malnutrition will help target resources to prevent further deterioration in patient nutritional status.


The key objective for this project is to raise awareness of the importance of a patientâ&#x20AC;&#x2122;s nutritional status and nutritional care before and during their admission to hospital. There is presently a lack of access to equitable nutritional care across all inpatient groups. This is a problem across all disciplines and stems from a lack of knowledge across our health professionals, food service teams and management to identify the issues impacting nutritional status of patients and the interventions required to address these. Nutritional screening in the adult hospital population should be mandatory. It will help identify malnutrition and persons at risk of malnutrition and enable appropriate nutritional intervention.

Hospital malnutrition is a well recognised and world-wide phenomenon that has clinical and financial implications. It complicates illness, delays recovery, prolongs hospitalisation and increases the need for further interventions and highdependency nursing care.



Getting the right food to the right patient at the right time will improve nutritional status and this requires a multidisciplinary team effort.

Future objectives â&#x20AC;˘ 90 percent of all inpatients are weighed within 24 hours and all patients will have weight and height recorded â&#x20AC;˘ 80 percent of ward patients have a nutritional screening tool assessment done within 24 hours of admission and appropriate intervention if required.



Quality improvement projects Here is a selection of the quality improvement projects that have been implemented or are underway at Auckland District Health Board.


Central intravenous additive service (CIVAS) – provide intravenous drugs in a ready-to-use form from the pharmacy in order to release nursing time to care for patients.

Reduction in avoidable re-admissions – promptly identify patients at high risk and provide enhanced discharge planning in hospital and earlier follow-up when they are back in the community.

ACC treatment injuries – increase funding from ACC for treatment of injuries, through education and awareness.

Maternal diabetes clinic wait times – reduce waiting time for patients (which can be up to five hours) by matching resources to patient demand and optimising clinic facilities.

Mid-stream urine test reduction – educate and raise awareness of the technique to get a good sample first time around, saving patient time and health dollars. Materials management – significantly reduce waste in materials by improving processes and focusing on having the right amount of products in the right place at the right time. Phlebotomy Service – increase the number of collections carried out by the inpatient phlebotomy service. LabPlus Chemical Pathology Automation Area Design – improve turnaround times for samples to be registered and processed by redesigning the lab sample registration and automation work. Outpatient intravenous antibiotic (OPIVA) service – explore whether provision of pre-mixed antibiotic syringes is appropriate for OPIVA patients in order to facilitate earlier discharge from hospital.

Epsom Day Unit – provide a choice of termination method that meets the requirements of the Abortion Supervisory Council and improves patient experience. Privacy complaints – make sure all complaints are resolved within ninety days – reducing stress for patients and staff and risk of legal action. Early identification of dementia – improve processes and raise awareness so that patients with dementia are identified within their first twenty-four hours of admission so they get the right care sooner (currently estimated to be between three and five days). Reducing follow up appointments – stop unnecessary follow ups in ear, nose and throat by introducing more effective protocols and moving appropriate follow ups to GPs and Clinical Nurse Specialists.


Recording service delivery and patient treatment/care – improve how data is captured and shared during a patient’s stay to avoid rework and delays in discharge.

Bereavement services – communication to raise awareness of the cultural issues to be respected in the lifts that carry deceased persons (Tupapaku).

Scheduling General Surgery elective sessions – changes have resulted in almost six hours additional operating time each week.

Enhanced recovery after surgery – optimise colorectal surgical patient’s preparation and care during surgery to reduce the average length of stay.

Fleet optimisation – reduce the number of fleet vehicles to the required level avoiding vehicle and associated costs incurred.

Surgical list case mix – increase the number of elective surgical procedures by maximising theatre use with optimum mix of patients to reduce ‘down time’ during Orthopaedics surgical lists.

Recycled and expired pharmacy stock – evaluate the process for dispensed and imprest medicine to reduce time and expired stock. Ear, nose and throat dizzy patients – implement a clinical pathway to improve the assessment and referral for patients with symptoms. Leading to a reduction in wait times and attending unnecessary specialist appointments. Day of surgery admission for neurosurgery – improve the pre-admit and admission process for neurosurgery patients. Theatres expired stock – reduce the waste in expired theatre stock through improved inventory management, resulting in significant financial savings. Antibiotic stewardship – ensure there is rational and appropriate use of antimicrobials in order to improve patient care, reduce antimicrobial resistance, and reduce costs.

Suspected Appendicitis – investigate the possible over requesting of scans which would result in saving patient time. Total Parenteral Nutrition (TPN) Clinic – establish the TPN clinic (where patients are fed intravenously) and associated processes providing a better patient experience. First dressing change – apply a seethrough dressing to the wound after surgery. This will reduce the need to remove the dressing within the first three days after surgery by forty percent and therefore reduce infection and cost. First Specialist Assessment increase (FSA) – improve processes to increase the number of General Surgery FSAs by 160 in 2012. Operating room day admission bed flow – reduce bed shortages for surgical patients and eliminate the need for Healthcare Assistants to search for beds (the equivalent of more than one day each month was spent doing this).

Reduce pressure sores and falls causing harm – a collaborative approach working with the aged care sector to reduce pressure sores and decrease the number of avoidable hospital falls by twenty percent. This is resulting in safer care and shorter stays in hospital. Diagnostic angiogram – reduced delays to diagnostic angiograms for non acute patients with Acute Coronary Syndrome admitted to the Coronary Care Unit. Bed turnaround time – reduced the time from a discharged patient vacating a bed in Starship to having the bed available for a new patient by one hour.

Elective case cancellations – reduced late elective case cancellations by an average of ten per month. This gives more assurance to patients that their operation is going ahead as planned and reduces rework for hospital staff. Reduce theatre session cancellations in General Surgery – Cancellations for surgery have halved from an average of three per week to one and a half. This means more patients are having their surgery sooner. Pre-admit improvement – improve patient experience prior to surgery by improving communication, standardising paperwork, enhancing scheduling and triage processes. Acute surgical patients – reduced the time patients in the Emergency Department and the Assessment and Planning Unit wait from the Acute Surgical team by fortyeight minutes, resulting in safer care and a better patient experience.

Bed scheduling – reduced the time Emergency Department patients wait for a bed in General Medicine by one hour.

Bed request to acknowledgement – ninetyfive percent of bed requests to be observed by a bed manager within fifteen minutes, an average reduction of twenty minutes per request, helping patients get to the right place for their care sooner.

Improve effectiveness of nursing care plans – improve patient safety and experience by making sure every patient has a high quality nursing care plan.

Expansion of Eye and Short Stay Surgical Ward – involving patients in the development of the new ward using experience-based design.

Auckland District Health Board Quality Account 2012/2013  

We are pleased to introduce the first Quality Account for Auckland District Health Board. The quality and safety of care continues to be our...

Auckland District Health Board Quality Account 2012/2013  

We are pleased to introduce the first Quality Account for Auckland District Health Board. The quality and safety of care continues to be our...