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HOSPITAL ADVISORY COMMITTEE MEETING

Friday, 23 March 2018 8.30 am

Education Facility Timaru Hospital Campus Queen Street, Timaru

MEETING OF THE HOSPITAL ADVISORY COMMITTEE

TO BE HELD ON FRIDAY, 23 MARCH 2018 AT 8.30 AM

IN ROOM 1, LEARNING HUB (Education Centre)

AGENDA

Items Action

1. APOLOGIES Receive

2. DECLARATIONS OF INTEREST Note Attached

3. CONFIRMATION OF MINUTES OF MEETING HELD 26 JANUARY 2018 Resolution

Attached

4. MATTERS ARISING FROM THE MINUTES Receive Verbal

5. HOSPITAL ADVISORY COMMITTEE ACTION LIST Receive

Attached

6. FINANCIAL REPORT Receive Attached

7. BASE MEDICAL/SURGICAL VOLUMES & HEALTH TARGET – ELECTIVE SERVICES

DISCHARGES Receive Attached

8. KEY PERFORMANCE INDICATORS REPORT Receive

Attached

9. CLINICAL BOARD UPDATE Receive Attached

10. FACILITIES UPDATE Receive

Attached 11. HEALTH, SAFETY & WELLBEING REPORT Receive Attached 12. PUBLIC EXCLUDED RESOLUTION Receive

Attached

PUBLIC EXCLUDED

13. CCDM – CAPACITY AT A GLANCE Receive Presentation OIA 1982 S. 9 (2) (i) Commercial NZPHD Sch. 3 cl. 32 (a)

14. HOSPITAL ADVISORY COMMITTEE ACTION LIST Receive Attached OIA 1982 S. 9 (2) (i) Commercial NZPHD Sch. 3 cl. 32 (a)

15. QUALITY & PATIENT SAFETY REPORT Receive

Attached OIA 1982 S. 9 (2) (a) Privacy NZPHD Sch. 3 cl. 32 (a)

16. MATERNITY SERVICES REVIEW UPDATE Receive

Verbal OIA 1982 S. 9 (2) (i) Commercial NZPHD Sch. 3 cl. 32 (a)

17. ELECTIVE SERVICES BREAKDOWN Receive

Presentation OIA 1982 S. 9 (2) (i) Commercial NZPHD Sch. 3 cl. 32 (a)

18. EFFICIENCY PROJECTS Receive

Attached OIA 1982 S. 9 (2) (i) Commercial NZPHD Sch. 3 cl. 32 (a)

19. MHA REVIEW Receive

Attached OIA 1982 S. 9 (2) (i) Commercial NZPHD Sch. 3 cl. 32 (a)

20. RESUME PUBLIC SESSION RESOLUTION Receive

HOSPITAL ADVISORY COMMITTEE

Member Interest Register 23 March 2018

Paul Annear Elected SCDHB Board Member Physiotherapist in Private Practice (Timaru & Ashburton) Shareholder & Director – FAIM Holdings – Family Company Shareholder & Director – Timaru Holdings Director – McLeod Building, Invercargill Shareholder/Director Westhills Forestry Ltd Daughter employed by SCDHB as a NASC Assessor

Mark Rogers Appointed SCDHB Board Member Director, Dunedin International Airport Chairman, Aoraki Developments & Promotions Ltd Shareholder & Director, MVHB Holdings Ltd Director, ourGroupIT Ltd Treasurer, Kingsdown – Salisbury Hall Advisory Board Member – AquaPro Plumbing & Drainage Ltd Chairman, Advisory Board of Chris Broadhead Construction Group Committee Member, Institute of Directors – Canterbury Branch Advisory Board Chairman for Men at Work Group

Ron Luxton Appointed Chair, SCDHB Board Chair, Aoraki MRI Charitable Trust Justice of the Peace Trustee, Green-gables Trust. Member Temuka Lions Club Trustee Ward Family Trust Director, New Zealand Health Partnerships Ltd Director, South Canterbury Eye Clinic

Murray Roberts Appointed SCDHB Board Member Managing Director, Trust Aoraki Limited Consultant/Business Advisor to SGS New Zealand Ltd President, South Canterbury Rugby Football Union Inc Board Chair, Harlequins RFC Inc Public Shareholder; Green Cross Health Ltd Trustee – Morrison Family Trust Trustee – Meyer Family Trust Trustee – Roberts Family Trust Trustee – Aoraki Foundation

HAC Meeting 23 March 2018 2 - 1

Terry Kennedy Elected SCDHB Board Member Member South Canterbury Stroke Club

Michael Boorer Appointed SCDHB Board Member Member of the Order of St John Sister employed by SCDHB as a Hospital Aide at Talbot Park Director, Timaru Electricity Ltd Director, SmartCo Ltd Director, On Metering Ltd

Juliette Stevenson Maori Health Advisory Committee (MHAC) Member – Representative on HAC Timaru Mental Health Support Trust - Employee Victoria Trust – Board member Mother – Waihao representative of MHAC and MHAC representative on Community & Public Health Advisory Committee (CPHAC)

Deborah Whatuira Maori Health Advisory Committee (MHAC) Member – Te Aitarikihi Trust Representative Representative on Hospital Advisory Committee Employed by SCDHB as Stop Smoking Practitioner

Rebecca Jackson HAC Community Member

Sally Feely HAC Community Member Brother employed by SCDHB as Paediatric Nurse

Board members are reminded that they are responsible for notifying the Board through the Board Secretary of any changes in interests as soon as these occur. The disclosure must provide adequate information to enable a determination of the extent of the nature of the interest and to assess actions that may need to be taken to manage any conflicts that arise.


MINUTES OF THE MEETING OF THE HOSPITAL ADVISORY COMMITTEE HELD ON FRIDAY, 26 JANUARY 2018 IN ROOM 1, LEARNING HUB, TIMARU HOSPITAL, QUEEN STREET, TIMARU AT 8.30 AM. PRESENT Mr P. Annear (Chair) Mr M. Rogers (Deputy Chair) Mr M. Boorer Mr T. Kennedy Mr M Roberts Ms S Feely Ms R Jackson Ms J Stevenson APOLOGIES (Item 1) Ms D. Whatiura IN ATTENDANCE Mr R Luxton, Board Chair Mr N Trainor, Chief Executive Mr J. Power, Director Corporate Services Mrs L. Blackler, Director Patient Nursing & Midwifery Services Ms B Dore, Elective Services Manager Mrs N. Hoskins, Communications Manager Ms R Irvine, Minute Taker DECLARATIONS OF INTEREST (Item 2) The Committee Members Interest Register was noted with nil further changes. CONFIRMATION OF MINUTES OF MEETING HELD ON 24 NOVEMBER 2017 (Item 3) It was agreed that the minutes of the meeting of the Hospital Advisory Committee held on 24 November 2017 be confirmed. MATTERS ARISING FROM THE MINUTES (Item 4) Nil HOSPITAL ADVISORY COMMITTEE ACTION LIST (Item 5) The Committee received the report. FINANCIAL REPORT (Item 6) Management noted we are trending to be favourable to the IDF budget. The Chair requested an IDF report be included in future financial reports. It was noted that the demand for Pharmaceuticals is ahead of plan. Management informed we may have to increase the budget for PCT drugs, will depend on new drugs coming on plus the mix of patients. The Committee received the report. BASE MEDICAL/SURGICAL VOLUMES & HEALTH TARGET – ELECTIVE SERVICES DISCHARGES (Item 7) Management advised that the variances have slipped for Elective Services but that the plan is to double the target for January 18 to catch up. The Chair asked that congratulations be passed onto the team. The Committee received the report.

KEY PERFORMANCE INDICATORS (Item 8) Members noted that the KPI for Complaints responded to within 23 days was 100% for Dec 17, a very good effort. The Chair asked that congratulations be passed onto the ED team that their KPIs are consistently green. The Committee received the report. CLINICAL BOARD UPDATE (Item 9) Management advised that the monthly meeting dates for Clinical Board meetings are shifting from 4th Tue to the 2nd Tue to facilitate more timely reporting. The Committee received the report. FACILITIES UPDATE (Item 10) Management advised that site planning work will commence with the DLA Group next week to progress projects for Emergency Department, Outpatients, Day Patients, Central Sterilising Unit and Endoscopy Suite. The Committee received the report. HEALTH, SAFETY & WELLBEING REPORT (Item 11) The Committee received the report. NATIONAL BOWEL SCREENING PROGRAMME UPDATE (Item 12) The Committee received the report. PUBLIC EXCLUDED RESOLUTION (Item 13) The Committee resolved that in accordance with the provisions of clause 32 of the 3rd

schedule of the New Zealand Public Health and Disability Act 2000 (“the Act”) that the public

be excluded from the following part of this meeting in order that the Committee may consider:

1. Hospital Advisory Committee Action List 2. Quality & Patient Safety Report 3. Maternity Services Review Update 4. HPHE Update 5. Efficiency Projects The reason for passing this resolution in relation to

• Hospital Advisory Committee Action List

• Maternity Services Review Update

• HPHE Update

• Efficiency Projects

is that the public conduct of this part of the meeting would be likely to result in the disclosure

of information for which good reason for withholding exists under the Official Information Act

1982, being -

(a) Information that would enable the Board to carry out, without prejudice or disadvantage, commercial activities (S. 9 (2) (i) Official Information Act 1982)

The reason for passing this resolution in relation to

• Quality & Patient Safety Report

is that the public conduct of this part of the meeting would be likely to result in the disclosure

of:

(a) Information that relates to the privacy of natural persons (S. 9 (2) (a) Official Information Act 1982)

RESUME PUBLIC SESSION RESOLUTION (Item 19) The Committee resolved to resume in open meeting and actions taken with the public

excluded were confirmed by the Committee.

There being no further business the meeting concluded at 9.25am.

Chair Date

HOSPITAL ADVISORY COMMITTEE ACTION LIST

as at 23 March 2018

Action Owner Dated Added Completion Due Status

1. Clinical Project Handover Report Penny Dewar 24 November 2017 23 March 2018 Update on progress

2. National Bowel Screening - Regular updates and financials when available

Ruth Kibble 24 November 2017 Ongoing

Completed Items to be retained for period of six months as reference and completeness of record

Action Owner Date Added Date Completed Status

1. Presentation of a Patient Journey for a Hip Replacement

Steve Earnshaw 27 July 2017 29 September 2017 Presentation completed

2.

Hospital Advisory Committee Meeting 23 March 2018 5 - 1

Memo

To: HOSPITAL ADVISORY COMMITTEE

From: Grant Keene, Finance Manager

Date: 13 March 2018

Re: Financial Reports – February 2018

Secondary Services Financials (Includes Timaru Hospital, Talbot & Support Services)

Summary Secondary Services & Support has a net $20k unfavourable to budget result for the month and a net $90k favourable to budget variance year to date. Revenue is favourable to budget YTD $359k. The main contributors were MOH Income $508k, made up of PCT & Community Drug revenue $515k off set by Unearned Mental Health revenue returned to the funder ($153k) ACC Income $88k Patient Income ($58k), Talbot Interest Income ($116k) reduced interest bearing deposits Other Income ($63k) Expenditure is unfavourable to budget by $269k Favourable variances in Personnel costs $990k, driven by Outsourced Services ($315k), Clinical Supplies ($737k), Infrastructure & Non Clinical Supplies ($211k) Forecast There is no change to the forecast which is predicting a surplus of $11k


South Canterbury District Health Board 2017/18 2017/18 2017/18 2017/18 2017/18 2017/18 2017/18 2017/18

Provider Financial Performance Actual Budget Variance YTD Act YTD Bud Variance Forecast Budget

February 2018 Month Month Month YTD YTD YTD

MOH Income 7,287 7,158 129 ✓ 57,774 57,266 508 ✓ 86,517 85,901

ACC Income 149 153 (4) 1,310 1,222 88 ✓ 1,785 1,834

Patient Income 126 124 2 938 996 (58) 1,380 1,496

Interest Income 79 98 (19) 668 784 (116) 1,009 1,176

Other Income 241 238 3 1,717 1,780 (63) 2,567 2,664

Total Revenue 7,882 7,771 111 ✓ 62,407 62,048 359 ✓ 93,258 93,071

Personnel Benefit Costs 5,080 4,975 (105) 42,096 43,086 990 ✓ 64,004 64,695

Outsourced Services 680 697 17 ✓ 5,891 5,576 (315) 8,768 8,364

Clinical Supplies 1,042 991 (51) 8,665 7,928 (737) 13,147 11,884

Infrastructure & Non Clincal Supplies 943 951 8 ✓ 8,022 7,811 (211) 11,892 11,598

Internal Allocation (64) (64) - (512) (508) 4 (762) (762)

Total Expenditure 7,681 7,550 (131) 64,162 63,893 (269) 97,049 95,779

Net Result (Deficit)/Surplus 201 221 (20) (1,755) (1,845) 90 ✓ (3,791) (2,708)

Gains/(Losses) on Property Revaluations

TOTAL COMPREHENSIVE INCOME 201 221 (20) (1,755) (1,845) 90 ✓ (3,791) (2,708)


South Canterbury District Health Board 2017/18

Provider Financial Performance Variance

February 2018 YTD

MOH Income 508 PCT Drug $515k, Community Drugs $24, MOH Initiatives $57k, Peronal $47k off set by Unearned Mental Health revenue ($153k)

ACC Income 88 Primary Health $126k, District Nursing $32k, Occupational Therapy $27k, Electives services $34k, AT&R ($93K),

Physiotherapy($33k)

Patient Income (58) Talbot ($111k), MRI Services ($43k), Held Budget $44k, Maternity $44k

Interest Income (116) Decrease in interest bearing deposits

Other Income (63)

Other Health Contract (Pharmac Hospital Rebate coding change to expense) ($178k), GP Cost Recovery ($109k) Loss on sale of

fixed assets ($15k) off set by Non Clincal revenue (Laundry) $138k Other Sale ofHealth Goods Goods $71k, Sundry revenue $39k

Total Revenue 359

Personnel Costs 990 Medical Staff $1,636k favourable to budget off set by Outsourced Medical Staff ($1,341k), Nursing $339k, Allied $356k, Support

($111k), Admin & Management $111k

Outsourced Services (315) Outsourced Clinical Services ($315k). The Outsourced unfavourable to budget variance is driven by Radiology ($295k), Pathology

($226k), Treasury ($60k), Primary Health ($47k), Orthopaedic ($41k), Urology (24k)off set by held Budgets $360k

Clinical Supplies (737) Pharmaceuticals ($599k) , Instuments & Equipment ($205k), Diagnostic Supplies ($27k), Implants $104k

Infrastructure & Non Clincal Supplies (211) Other Operating Expenditure ($173k), Professional Fees ($70K), Catering & Cleaning ($82k), IT/Telecoms $68, Facilities $48k

Internal Allocation 4

Total Expenditure (269)

Net Result (Deficit)/Surplis 90


Personnel Costs

Medical Personnel 1,636

Cost centres >$20k Casualty Officers $621k, Physicians $227k, GPs $222k, Otolarynologist $173k, Paediatrician $164k, General

Surgeons $164k, Anaesthetist $150k, Orthopaedic Surgeon $116k, Dental Surgeons $110k, Gynaecologist $84k, RMOs $77k,

Relocation costs SMO $64K, Training costs RMOs $52K, RMO Supervisor $24k, off set by Medical Officer (MOSS) ($425k), Locum

expenses ($116k), Psychiatrists ($30k), Medical recruitments ($24k), Clinical Directors ($20k)

Nursing Personnel 303

Cost Centres >$20k Charge Nurse Managers $99k, Midwife- Community $72k, Duly Authorised Officers $68k, Staff Nurses $100k,

Nursing Training costs $50k, Nurse Aids $48k, Clinical Educators $34k, Midwifes Hospital $22k, Clincal Associates $21k Enrolled

Nurses ($167k), Clinical Nurse Specialsits ($40k)

Allied Health Personnel 393 Cost centres >$20k Physiotherapists $154k, Occupational Therapists $81k, Social Workers $58k, Pharmacists $47k, Occupational

Therapists $43k, Psychologist $25k, Audiologist $21k, Technical Assistants $21k, Case managers ($54k)

Support Personnel 55 Cost centres >$10k Operating Theatre Manager $41k, Orderlies $13k, Supply $13k, Laundry $11k off set by Elective Services ($18k)

Management/Administration Personnel 136 Director Corporate services $78k, Staff Development $44k, Health & Safety $37k, CEO Office $25k, Mental health $23k, Held Bidget

($33k), Mental Child & Youth ($32k)

SCDHB Employee costs 2,523

Medical Personnel (1,341)

Cost Centres >$20k, Emergency ($326k), Orthopaedics ($211k), Gynaecology ($225k), Paediatrics ($177k), General Surgery

($175k), GP Locums (120k), Anaesthetic ($92k), General Medicine ($88k), off set by Psychiatry $53K, Ophthalmology $29k, Alcohol

& Drugs $13k

Nursing Personnel 36 Maternal Child & Youth $15k

Allied Health Personnel (37) District Nursing $26k

Support Personnel (166) Laundry ($164k)

Management/Administration Personnel (25) Clerical Support ($31k)

Outsourced Personnel Costs (1,533)

Personnel Benefit Costs Total 990

Outsourced Clinical Services (312) Radiology ($296k), Pathology ($225k), Treasury SCEC ($60k),Primary health ($47k), Orthopaedics ($41k), Urology ($24k), General

Medicine $25k off set by held Budgets $360k

Outsourced Corporate/Governance Services (3)

Outsourced Clinical Services Total (315)


Clinical Supplies

Treatment Disposables (1)

Diagnostic Supplies & Other Clinical Supplies (27) Medical Supplies - >$20k, Theatre ($50k), Facilities ($26k), IV Fluid ($22k), Surgical $24k, Treasury $68k

Instruments & Equipment (205) Depreciation ($182k) off set by R&M ($13k)

Patient Appliances (13)

Implants and Prostheses 104 Theatre $46k, Held Budgets $54k

Pharmaceuticals (599) Demand ahead of plan

Other Clinical & Client Costs 4

Clinical Supplies Total (737)

Infrastructure & Non-Clinical Supplies

Hotel Services, Laundry & Cleaning (82) Patient Meals ($60k), Other Catering ($23k)

Facilities 48 >$20K, Depreciation $256k, R&M ($118K), Rents & leases ($46k), Electricity ($16k), Coal ($29k)

Transport (2)

IT Systems & Telecommunications 68 Contracted processing $33k, Hardware/Software Maintenance $12k, IT Depreciation $24k

Interest & Financing Charges -

Professional Fees & Expenses (70) Contracted Support ($96k), Legal Fees ($23k), Consultants $50k

Other Operating Expenses (173) R&M ($60k), Stationary/Printing ($36k), Outwards Freight ($36k), Equipment Leases ($24k), Sundry expenditure ($24k)

Democracy -

Subsidiaries, Joint Ventures & Minority Interests -

Infrastructure & Non-Clinical Supplies Total (211)


IDF Expenditure IDF Inpatient Outflows were favourable to budget by $2.1million YTD January 2018 The graph below highlights the favourable variances (accumulative) in green from September 2017 to January 2018

-

2,000,000

4,000,000

6,000,000

8,000,000

10,000,000

12,000,000

Sept Oct Nov Dec Jan

Actual

Budget

Variance


MEMO To: Hospital Advisory Committee From: Lisa Blackler, Director of Patient , Nursing and Midwifery Services Date: 18 March 2018 Re: HEALTH TARGET - ELECTIVE SERVICES DISCHARGES

PROGRESS FROM 1 JULY 2017 TO 31 JANUARY 2018

Health Target - Elective Services Discharges progress from 1 July 2017 to 31 January 2018

Service YTD Planned Discharges

YTD Actual Delivery

YTD Variance % YTD Delivery

General Surgery 436 427 -9 98%

Skin Lesion 38 41 3 108%

Anaesthesia 104 123 19 118%

Cardiothoracic 19 20 1 105%

ENT 208 185 -23 89%

Gynaecology 168 192 24 114%

Neurosurgery 23 34 11 148%

Ophthalmology 206 199 -7 97%

Avastin 0 2 2

Orthopaedic Surgery 305 251 -54 82%

Paediatric Surgery 12 10 -2 83%

Plastics & Burns 26 35 9 135%

Urology 12 13 1 108%

Vascular 13 19 6 146%

Elective non-surgical 30 31 1 103%

Arranged surgical 145 152 7 105%

Arranged non-surgical 47 36 -11 77%

Health Target Total 1,792 1,770 -22 98.8%

This report covers the MOH Elective Services Health Target delivery for the 2017/18 year only. IDFs take longer to finalise and we do not have the final delivery until approximately 6 weeks after month end. Preliminary data for February 2018 shows delivery to be at 97.3%.

Recommendation That the Committee receives this report.


South Canterbury District Health Board 12 month trend to January 2018 - Patients receiving diagnostics within required timeframes

South Canterbury

201,702.00February

2017

201,703.00March

2017

201,704.00April

2017

201,705.00May

2017

201,706.00June

2017

201,707.00July

2017

201,708.00August

2017

201,709.00September

2017

201,710.00October

2017

201,711.00November

2017

201,712.00December

2017

201,801.00January

2018

201,801.00

12 monthtotal:

Waiting or catheterised in 90 days (3 months) or less

Coronary Angiography Total number waiting or catheterised

% of Coronary Angiographies in 90 days (3 months) or less

Waiting or scanned and reported in 42 days (6 weeks) or less

CT Scan Total number waiting or scanned and reported

% of CT scans in 42 days (6 weeks) or less

Waiting or scanned and reported in 42 days (6 weeks) or less

MRI Scan Total number waiting or scanned and reported

% of MRI scans in 42 days (6 weeks) or less

Waiting or scoped in 14 days (2 weeks) or less

Urgent Colonoscopy Total number waiting or scoped

% of urgent colonoscopies in less than 2 weeks (14 days)


Non-urgent Colonoscopy Total number waiting or scoped

% of non-urgent colonoscopies in 42 days (6 weeks) or less


Surveillance Colonoscopy Total number waiting or scoped

% of surveillance colonoscopies in 84 days (12 weeks) or less

---

G269279

96.4%

126132

95.5%

8

8

100.0%

46105

43.8%

3445

75.6%

---

G324333

97.3%

166169

98.2%

11

13

84.6%

54111

48.6%

3758

63.8%

---

G258265

97.4%

148152

97.4%

3

4

75.0%

4477

57.1%

2231

71.0%

---

G281289

97.2%

160165

97.0%

10

11

90.9%

4493

47.3%

2636

72.2%

---

R261275

94.9%

146149

98.0%

7

7

100.0%

72101

71.3%

3438

89.5%

---

R287306

93.8%

118123

95.9%

5

5

100.0%

4565

69.2%

1214

85.7%

---

G296310

95.5%

143148

96.6%

10

10

100.0%

4874

64.9%

3944

88.6%

---

G263269

97.8%

116117

99.1%

3

3

100.0%

79103

76.7%

2222

100.0%

---

G213223

95.5%

126126

100.0%

5

5

100.0%

54100

54.0%

1212

100.0%

---

G254262

96.9%

149153

97.4%

8

8

100.0%

5795

60.0%

1616

100.0%

---

R240253

94.9%

121124

97.6%

7

8

87.5%

47107

43.9%

814

57.1%

---

R294311

94.5%

151153

98.7%

9

9

100.0%

33106

31.1%

2529

86.2%

---

3,2403,375

96.0%

1,6701,711

97.6%

86

91

94.5%

6231,137

54.8%

287359

79.9%

This is a Policy Priority

NOTES

1. Data was provided by DHBs for the first time in July 2012 2. This was a Development Indicator until June 2014. 3. The information is being shared to continue to improve accuracy and understanding of the data report and to improve data quality4. The data will remain variable as DHBs work to understand reporting requirements and improve data collection5. Please advise of any concerns you have about the quality of data you have supplied6. Please ensure that if this data is shared, these caveats are included.

BOX 1: Indicator Levels

In the 2017/18 financial year the following waiting time indicators apply :Coronary Angiography: 95% of people accepted for elective angiography receive their procedure in 90 days (3 months) or lessComputed Tomography (CT): 95% of people accepted for a CT scan receive their scan in 42 days (six weeks) or lessMagnetic Resonance Imaging (MRI): 90% of people accepted for an MRI scan receive their scan in 42 days (six weeks) or lessUrgent Colonoscopy: 90% of people accepted for an urgent colonoscopy receive their procedure in 14 days (two weeks) or lessNon-urgent Colonoscopy: 70% of people accepted for a non urgent colonoscopy receive their procedure in 42 days (six weeks) or lessSurveillance Colonoscopy: 70% of people accepted for a surveillance colonoscopy whose procedure is due prior to or within the month of reporting receive their procedure in 84 days (12 weeks) or less

BOX 2: Calculation

Numerator:

Denominator: People who received the diagnostic and people waiting for the diagnostic at the end of the period

People who received* the diagnostic within the identified timeframe and People waiting for the diagnostic at the end of the period who have waited less than the indicated timeframe

BOX 3: Indicator Triggers BOX 4: Data source:The indicator will be Green if:

Angiography data is supplied by DHBs to the National Booking Reporting System (NBRS), and extracted monthly

CT and MRI data is supplied by DHBs on a spreadsheet report each monthColonoscopy data for most DHBs is supplied on a spreadsheet report each month. Four DHBs are reporting colonoscopy via NBRS

1. The DHB percentage result is at or above the level identified in Box 1

The indicator will be Red if:

1. The DHB percentage result is below the level identified in Box 1; or2. The DHB has not supplied data; or the DHB data is incomplete

Report Run Date: 26 February 2018

Developmental Indicator Policy Priority2012/13 2013/14 2014/15 2015/16 2016/17 2017/18

Coronary Angiography 85% within 90 days 85% within 90 days 90% within 90 days 95% within 90 days 95% within 90 days 95% within 90 daysCT Scan 75% within 42 days 85% within 42 days 90% within 42 days 95% within 42 days 95% within 42 days 95% within 42 daysMRI Scan 75% within 42 days 75% within 42 days 80% within 42 days 85% within 42 days 85% within 42 days 90% within 42 daysUrgent Colonoscopy 50% within 14 days 50% within 14 days 75% within 14 days 75% within 14 days 85% within 14 days 90% within 14 daysNon-urgent Colonoscopy 50% within 42 days 50% within 42 days 60% within 42 days 65% within 42 days 70% within 42 days 70% within 42 daysSurveillance Colonoscopy 50% within 84 days 50% within 84 days 60% within 84 days 65% within 84 days 70% within 84 days 70% within 84 days

BOX 5: Previous Indicator LevelsThe following waiting time indicators applied while this was a Developmental Indicator:

BOX 6: Data requirements

*Please note a patient is considered to have received their CT or MRI scan once the report from the scan has been distributed.


MEMO To: Hospital Advisory Committee From: Lisa Blackler – Director of Patient Nursing and Midwifery Date: February 2018 Re: ELECTIVE SERVICES REPORT AND INFORMATION

Report Please find included breakdown of current surgical caseweight and discharge performance including ESPI compliance and National comparison. The data includes local data and MoH data in comparison. The final report being indicative of the month snapshot from the Elective Services Manager. Period 1 July to 28 February 2018 unless indicated otherwise.


ORTHOPAEDIC AND GENERAL SURGERY DELIVERY AGAINST AGREED PLAN JULY – TO JAN 2018


MAJOR JOINTS DELIVERY TO AGREED PLAN YTD


NON-JOINT ORTHOPAEDICS DELIVERY TO AGREED PLAN YTD


GENERAL SURGERY DELIVERY TO AGREED PLAN YTD


ELECTIVE SERVICES PATIENT FLOW INDICATOR


NATIONAL COMPARISON OF ELECTIVE SERVICES PATIENT FLOW INDICATORS


ELECTIVE SERVICES PATIENT FLOW INDICATORS – AREAS IN RED ESPI 5


Elective Services Narrative for February 2018

Completed by B Dore

Month

Target

Month

Actual

Month

Var.

Month

%

YTD

Target

YTD

Actual

YTD

Var.

YTD

%

Elective CW 210.7 164.3 -46.4 -22% 1718.1 1523 -195 -11.3%

Acute Arranged CW 155.9 173.9 18 +11.5% 1261.9 1,345.2 83.4 +6.6%

Health Target Discharges* 208 185 -23 -11% 1687 1622 -65 -3.9%

Cataracts Intervention Rate * 23 33 +10 +43% 137 192 55 +40%

Major Joints Intervention Rate * 15 11 -4 -27% 110 120 10 +9%

Endoscopy 65 36 -29 -45% 520 468 -52 -10%

Urgent Colonoscopy wait time 90% 100% 90% 100%

Non-urgent colonoscopy “ “ 70% 31.1% -38.9% -38.9% 70% 31.1% -38.9% -38.9%

Surveillance colonoscopy “ “ 70% 86.2% +16.2% 70% 86.2% +16.2%

ESPI 5 compliance Green Red Red Green Red Red

CW per session 2.72 2.51 -0.21 -7.7% 2.72 2.51 -0.21 -7.7%

Theatre Session utilisation 77.2% 77.3% +0.1% +0.1% 77.2% 77.3% +0.1% +0.1%

ALOS (inpatients) 4 3.8 -0.2 -5% 4 3.8 -0.2 -5%

Surgical Implants $ 129,432 98,459 -30,973 -23.9% 1,035,452 989,054 -46,398 -4.5%

Budget $ 1,587,459 1,548,649 +38,810 +2.4% 13,201,267 12,827,885 -373,383 -2.8%

FTE -Service 107.7 110.6 +2.9 +2.7% 107.7 106.6 -1.1 -1%

FTE - Surgical 35.7 36.7 +1 +2.8% 35.7 35.4 -0.3 - 0.8%

FTE – Operating Theatre 24.7 27.5 +2.8 +11% 24.7 25.6 0.9 +3.6%

FTE – Day Patient Services 9.4 9.3 -0.1 - 1% 9.4 9.4

Appraisals % 90% 74.3% -15.7% -15.7% 90% 74.3% -15.7% -15.7%

High Leave balance % 14% 18.1% +4.1% +4.1% 14% 18.1% +4.1% +4.1%

All figures above refer to provider arm throughput and do not include IDF outflows. *these are estimated totals, as coding not yet complete

Highlights

• Surgical Ward: Medical bed nights decreased significantly to only 45 in February compared to 240 in January. Surgical occupancy reduced from 90% to 77.8% for the month.

• Ophthalmology: Cataracts estimated 33 over target YTD. Monthly volume ahead of target to assist discharges for provider arm catch up.

• Joints: 11 estimated discharges for February. YTD estimated 10 ahead of target • Endoscopy Waiting Times: Report for January: Urgent colonoscopies 100%, and

Surveillance 86.1%. From March we will have increased resource with 5th general surgeon commencing endoscopy lists as planned.

• Theatre Session Utilisation: Increased to 77.3% up from 67.3% last month. • Theatre time utilisation: 3rd highest for YTD at 91.7% with orthopaedics meeting

target of 95% and all but ophthalmology 90% or over.(Plan to increase to 7 cataracts per list as appropriate to increase utilisation)

• Staffing: Noted continued low utilisation of casual staff usage across the service. ➢ Casual Staff Usage: Operating Theatre: 1.09%. DPS: 3.43%. Surgical 2.58% ➢ Sick leave: Day Patient Services now 0.57% compared to 1.66% last month.

Surgical 3.9 % compared to 2.46% last month. Operating theatre 3.98% compared to 1.76% in January.

• Vacancies: Nil permanent medical vacancies in Elective Services currently. Dr Magda Sakowska General Surgeon commenced as planned on 26th February with her first week undertaking orientation to the organisation.

• Capex: Completion of capex expenditure continues as planned. Preparatory work undertaken for installation of new steriliser now planned for mid March. Capex request for low temperature steriliser almost completed and Phaco machine to go out to tender with in the next two weeks with the assistance of Southern Procurement staff.


• High leave balances: Currently 18.1% compared to 16.3% in January. Those staff with high level balances continue to be monitored by line managers with leave planned and pay out of leave as appropriate.

Challenges

• Health Target Discharges: Indicative reporting states we are now 65 discharges behind target compared to 42 discharges last month. This is largely as a result of an orthopaedic surgeon still being on sick leave which has led to an increase in acute activity on elective lists due to complexity of injuries. A recovery plan is being developed for orthopaedics in particular as a result of extended unplanned sick leave and the impact that is having on service delivery i.e. 68 discharges behind planned target YTD. 2 additional lists were undertaken in February for ENT to assist with both discharge and ESPI recovery in general.

• Endoscopy Waiting Times: Report for January: Noted ongoing high demand in non urgent category and we only achieved 31.1 %. The focus continues on ensuring that prioritisation is consistent and referrals are appropriate and meet the access criteria. This is being monitored by Clinical Director General Surgery.

• ESPI’s: ESPI 5 remains non compliant red in January however we will be non compliant yellow in February as a result of intensive monitoring of theatre lists and ensuring that long wait patients were not cancelled during this time. This has ensured that we have only been red for two consecutive months.

• Performance Appraisals: Service Manager and relevant Clinical Directors have completed 5 SMO appraisals, with Orthopaedic service now at 100%, General Surgery 80% (1 to be completed). Planning underway with CD’s Anaesthesia and O+G to complete outstanding appraisals in these services. Service Manager is also assisting Clerical Team leader to undertake outstanding appraisals of staff in the Inpatient Booking Office.

• Vacancy: Co-ordinator Elective Services has tendered her resignation. Consideration being given to seconding a staff member in the interim until a decision is made regarding the role in light of HPHE programme.

Recommendation That the Committee receives this report.


SOUTH CANTERBURY DISTRICT HEALTH BOARD

For the HAC Meeting 23 March 2018

Prepared by: Nigel Trainor, Chief Executive Officer

Report Title: KPI Report _________________________________________________________________________

Timaru Hospital was “green” on 8 measures, these being:

• Blood Stream Infection Rate

• ALOS – Elective Surgical

• Outpatient DNA rate

• Staff turnover rate

• 4 ED measures Timaru Hospital was “yellow’ on 2 measures, these being:

• ALOS – Acute result is consistent with last year, but short of the relatively aggressive target set for 2017/2018.

• Elective cost weights, improving trend, however Provider Arm elective costweight delivery remains lower than plan at the end of February

Timaru Hospital was “red” on 7 measures, these being:

• Complaints responded within 23 days 82%, performance is below target and the level achieved last year

• Elective Theatre Time Utilisation was 90.8% overall, the best performers were Gynae, and Dental approaching the target (93%) and Orthopaedics meeting target. Improvement needed across other specialties.

• Smoking Intervention Rate YTD 94%. YTD result is below target and the level achieved in prior years.

• Appraisals completed, this continues to be an area for attention with only one service groups complying with target at the end of January.

• High Leave Accrual – improvement noted this year with 120 employees exceed limit, 11 above targeted level.

• Work Injury Rate – fifteen new work-related accidents reported year to date. Exceeds annual target (12) and likely to exceed ten year annual average (16).

• Work Injury – Lost Days: no employees on accident leave at the end of February. One longer term case accounts for a third of lost working time.

Recommendation That the Board:

• Receives this report


SCDHB KPI - Report Card February 2018

Quality

Bloodstream Infection Rate Good Complaints Responded <23 Days Bad

Prior Years This Year Prior Years This Year

Target <= 0.6 Target = 100%

YTD 0.6 YTD 82%

Operational

ALOS - Elective Surgical Good ALOS - Acute Caution


Target <= 1.4 Target <= 2.3

YTD 1.4 YTD 2.7

Elective Costweights - Variance Caution Outpatient DNA Rate Good


Target >= 0.0% Target <= 3.0%

YTD -11.5% YTD 2.6%

Elective Theatre Time Utilisation Bad Smoking Intervention Rate Bad


Target >= 95.0% Target >= 95%

YTD 90.8% YTD 94%

Human Resources

Staff Turnover Rate Good Appraisals Completed Bad


Target <= 9.0% Target >= 90%

YTD 10.2% YTD 76%

High Leave Accrual - % >2 Years Bad Work Injury - Rate Bad


Target <= 14.0% Target <= 10.0

YTD 15.3% YTD 20.5

Work Injury - Lost Days Bad

Prior Years This Year

Target <= 10.0

YTD 27.1

Emergency Department

Triage 1 - Seen Immediately Good Triage 2 - Seen in 10 Minutes Good


Target = 100.0% Target >= 80.0%

YTD 100.0% YTD 82.7%

Triage 3 - Seen in 30 Minutes Good ED - Discharged within 6 Hours Good


Target >= 75.0% Target >= 95.0%

YTD 77.9% YTD 97.0%

Target achieved year to date.Target missed by a narrow margin in July/August. Improved performance

since September pulls the result back on track.

Consistently achieving at 100% mark. Target achieved year to date.

✓ ✓

✓ ✓

Improvement noted this year. 120 employees exceed limit, 11 above

targeted level.

Fifteen new work-related accidents reported year to date. Exceeds annual

target (12) and likely to exceed ten year annual average (16).

✕

No employees on accident leave at the end of February. One longer term

case accounts for a third of lost working time.

Turnover is within the expected range.Only one of six service groups is compliant with target at the end of

January.

✕ ✕

✓ ✕

✕

Performance is below target and the level achieved last year.

✓

Three infections reported year to date.

✓ !

Target achieved.Result is consistent with last year, but short of the relatively aggressive

target set for 2017/2018.

! ✓

Improving trend, however Provider Arm elective costweight delivery remains

significantly lower than plan at the end of February.Result is favourable to target.

✕ ✕

Orthopaedics achieving target. Dental and Gynaecology approaching target

(93%). Improvement needed across other specialties.Year to date result is below target and the level achieved in prior years.


MEMO

To: SCDHB Board

From: Robbie Moginie, Director Organisational Capability and Safety

Date: 15 March 2018

Re: CLINICAL BOARD UPDATE

The following is a summary of the Clinical Board Meeting held 13 March 2018.

• A presentation on the outcomes of a de-prescribing research project was presented by Nagham

Ailabouni relating to Pharmacy led deprescribing recommendations for aged residential care

patients. The 3 month and 6 month result was positive with no decline in mental or physical

functioning. Nagham then presented a proposed study which has been designed in partnership

with CDHB to extend the study into a younger cohort of patients in the community. Discussion

centred around the need for GP involvement to ensure pharmacy recommendations are well

received and further study which may explore alternative methods for encouraging deprescribing in

South Canterbury.

• An action plan was presented by Katherine Robinson from Mental Health which arose out of a 2017

Mental Health Review driven by a number of indicators of quality and safety improvement

opportunities. Some actions have already been completed while some are underway. Due to the

fact that the action plan is still in draft, the presentation was received but the action plan was not

commented on.

• The Adverse Event (Incident) Management Policy was approved subject to some minor editorial

changes.

• Challenges recruiting to the position of Orthopaedic Surgeon were discussed

• There was a discussion about the challenges of recruiting and retaining midwives across the region.

SCDHB is currently experiencing some pressures in this space


• Receives the report.


Memo

To: DHB BOARD

Copy To: SLT, HAC, Audit & Assurance Committee

From: Simon Johnston – Maintenance/Facility Manager

Date: 9 March 2018

Re: Facilities Update

Project Status Proposed

Completion

Helipad Draft copy Resource Consent Application has been issued to the DHB for review. Once finalised will be issued to the Council

Q3 2017/18

Seismic – Laundry and Supply Buildings

Current Standard of Laundry Building is 13% NBS Current Standard of Supply/Maintenance is 15% NBS There is no requirement under the building act to improve this rating. The Council are working on a list of at risk buildings and at the completion of that will issue a notice to the Building owner to improve/remove the building. Early signs are 15 years from the date of notice. A Engineering report has been requested for advice on both the Supply and Laundry buildings

Q3 2017/18

Medical gases – replacing oxidised pipes

Working on list of departments left to be transferred to work out final costings

Q3 2017/18

CSB Heating, Cooling Shades and Window Treatments

Structural Review being done on the roof of ED to install 1 unit, Main unit on top of CSB is to be commissioned the week of March the 12th Successful tender has been on site to do final measure up and ordering process, ETA on delivery times to follow

March 2018 February 2018 April 2018

CSU Sterilizer & Reverse Osmosis plant

New Steriliser with steam to steam generator has been installed and commission

March 2018

Hospital Advisory Committee Meeting 23 March 2018 10 -

Site Master Plan Interim Solutions Updates

Emergency Department and Outpatients Department

Level 1 available space has been mapped out, now to work through department requirements for the spaces.

Q2 2017/18

Central Sterilization Department Re-development

Architects completing drawings for RFP. Q3 2017/18

Café Re-location

Updated plan to be submitted on Cafe for review. Q3 2017/18

Medical Day Stay Drawings completed, final review by working group to be completed.

Q4 2017/18


• Receives this report Simon Johnston

Hospital Advisory Committee Meeting 23 March 2018 10 -

Memo

To: DHB BOARD

From: Peter Moore, Health, Safety & Wellbeing Manager Date: 8th March 2018 Re: Health, Safety & Wellbeing Report

Recommendation That the Committee:

• Receives this report Peter Moore


Health, Safety & Wellbeing Board Report

Report prepared by: Peter Moore, Health, Safety & Wellbeing Manager

Date: 8th March 2018

Health and Safety Committee Meetings

The February meeting was well attended and lots of open discussion held – it has been great to see how many are becoming more empowered to contribute. We talked about the importance of our workplace inspection process and how this is one of the most pivotal activities that can demonstrate proactive and accountable hazard identification/risk management.

We had a really rewarding workshop looking at training opportunities for the Health & Safety Representatives, this included creating a better understanding of role requirements and how wellbeing crosses all Health & Safety activity (which they are more aware about and tend to focus their attention).

For your information a summary of the session findings:

Identifying HSR

development opportunies.docx

Unfortunately, there was no Board member attendance again. The group do value this involvement and want to be challenged.

Health, Safety & Wellbeing Processes

I took possession of an indoor air quality meter/data logger and can now set up recordings in areas who may raise a concern, providing data that can help inform decision making.

We have identified an opportunity to review our pre-employment screening processes, with a particular focus on vaccination history and requirements.

The hazardous substances management improvement plan for one department is on-going and we are nearing a point where a number of action points could be closed out.

A requirement of the new Hazardous substances regulations is that staff are trained in safe use, handling, transportation etc. Angela Bell has written a training package that we would like to share regionally and have all staff access through HealthLearn, this is a great example of how we can invest time and effort into becoming a leader within Healthcare Health & Safety.

Further planning work has been conducted for the upcoming Influenza vaccination campaign. Vaccinators are being identified and timetables drafted. An aspirational target of 80% has been set.

Two clarification points on questions asked last month:

1. No charges are made for fire service callouts (there used to be a limit of 3 in any 12-month period).

2. Workplan action points 11 & 12. No regional agreement has been reached yet for the employee participation agreement (we currently have our own document that satisfies our obligation on this matter). The Directors are not currently having H&S activity reported to them. The following dashboard would, I expect help to highlight some focus areas to include in line reports.


Employee Incidents by Type:

↓

Reported Incident Type

Q 3

To

tal

Q 4

To

tal

Juy 2

017

Aug 2

01

7

Sep 2

01

7

Q 1

To

tal

Oct 2017

Nov 2

01

7

Dec 2

01

7

Q 2

To

tal

Jan 2

018

Feb 2

018

Mar

20

18

Q 3

To

tal

Apr

2018

May 2

018

Jun 2

018

Q 4

To

tal

Being hit by or hitting an object

1 5 1 1 2 1 2 1 4 1

Broken skin or laceration (Not BBFE)

1 4 1* 3 4 1 2 1 4 3

Chemical or other substance

1 1 1 1 1 1

Exposure to blood / body fluid (BBFE)

9 4 3 6 4* 13 2* 3* 3* 8 1

Exposure to heat, energy or radiation

1 0 1 1 0

Manual handling 3 1 1 1 0 3

Manual handling – patient

0 3 2 3 5 1 4 5 1 1

Muscular body stress or strain

3 7 2 2 2 6 2 3 1 6 1

Physical assault 11 11 1 3* 11 15 2 1 2 5

Psychological harm 2 3 1* 1 2 4 1 1

Road / traffic accident 1 0 1* 1 0

Slip, trip or fall 5 6 1 4* 1 6 1 2 3 2 1

Verbal abuse 5 3 1 1 2 4 1 1 3

TOTALS 43 48 14 20 28 63 11 15 12 38 11 7

* Near Miss incidents included above

2 1 1 4 1 6 1 1 2 4 0 0

Some totals will alter from those reported in previous months, due to completed investigations demonstrating incorrect classification of incident i.e. reported incidents become confirmed H&S (employee) incidents following investigation.


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

Corporate Services (8)** 38% 25% 13%

Patient, Nursing & Midwifery Services (12) 67% 67% 42%

Primary Health Partnerships & Allied Health (12) 75% 83% 83%

Organisational Capability & Safety (3) 67% 67% 67%

Support Office to the CEO (1) 100% 100% 100%

Total: 19% 29%

Late total (against previous quarter): 64% 61% 53%


Corporate Services 2 1

Patient, Nursing & Midwifery Services 3 1 1 1 1 2 3

Primary Health Partnerships & Allied Health 1 2 2 1 1 1

Organisational Capability & Safety

Support Office to the CEO

Total: 6 4 1 1 3 3 4 1


Corporate Services 5 5 4 1

Patient, Nursing & Midwifery Services 10 7 6 3 1 1 26

Primary Health Partnerships & Allied Health 2 2 33 2

Organisational Capability & Safety

Support Office to the CEO

Total: 17 14 6 3 1 1 63 3


Total number of documents 20 20 20 20 19 19 18 18 20

Total currently expired 0 0 0 0 0 0 0 0 0

Percentage complete 100% 100% 100% 100% 100% 100% 100% 100% 100%

Completed Workplace Inspection Checklists*

* Received within 2 weeks of a quarter ending (Target 100%) **Workgroup demonators

Employee Incidents With Unresolved Recommendations

Health, Safety & Wellbeing Policies / Procedures

Employee Incidents not closed within 30 days*

* Taget of zero (accepting that circumstances and incident complexity can result in a delay)

Dashboard/OverviewHealth, Safety & Wellbeing March 2018

Placeholder

Comments: There has been a geat response by closing managers dealing with open files and as such, the numbers are currently down to just one (audiology)

Comments: Security policy ready for SLT. Our H&S controlled documents have now migrated to the service framework and are aligned to Quality & Risk processes.

Comments: We can really celebrate closing manager efforts, following an unexpected peak last month due to the reporting issue that is now resolved. I am confident that I can now report on this activity acurately. Supportive training has been completed throughout the past month.

Comments: To date the receipt of workplace inspections checklists has declined overall, and in particular the Corporate / Patient, Nursing & Midwifery Services


RESOLUTION EXCLUDING PUBLIC

The Committee resolves that in accordance with the provisions of clause 32 of the 3rd schedule of the New Zealand Public Health and Disability Act 2000 (“the Act”) that the public be excluded from the following part of this meeting in order that the Committee may consider: 1. Hospital Advisory Committee Action Plan 2. CCDM – Capacity at a Glance 3. Quality & Patient Safety Report 4. Maternity Services Review Update 5. Elective Services Breakdown 6. Efficiency Projects 7. MHA Review

The reason for passing this resolution in relation to

• Hospital Advisory Committee Action Plan

• CCDM – Capacity at a Glance

• Maternity Services Review Update

• Elective Services Breakdown

• Efficiency Projects

• MHA Review

is that the public conduct of this part of the meeting would be likely to result in the disclosure of information for which good reason for withholding exists under the Official Information Act 1982, being - (a) Information that would enable the Board to carry out, without prejudice or

disadvantage, commercial activities (S. 9 (2) (i) Official Information Act 1982) The reason for passing this resolution in relation to

• Quality & Patient Safety Report

is that the public conduct of this part of the meeting would be likely to result in the disclosure of: (a) Information that relates to the privacy of natural persons (S. 9 (2) (a) Official

Information Act 1982)


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