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Quality Accounts 2013

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NATIONAL QUALITY MARKERS.................................................................................................................. 5 NATIONAL HEALTH TARGETS.................................................................................................................... 9

APPENDIX 1: QUALITY MARKER DASHBOARD ...................................................................................... 13

LOCAL QUALITY MARKERS........................................................................................................................ 2 INTRODUCTION ........................................................................................................................................... 1

OUR FUTURE FOCUS................................................................................................................................ 12

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CONTENTS

Acronyms used in this report CLAB Central Line Associated Bacteraemia DHB District Health Board ED Emergency Department GP General Practitioner HBDHB Hawke’s Bay District Health Board HQSC Health Quality and Safety Commission ICU Intensive Care Unit KPI Key Performance Indicator MoH Ministry of Health NGO Non Government Organisation PHO Primary Health Organisation RF Rheumatic Fever RPP Relapse Prevention Plans The Board Hawke’s Bay District Health Board’s governing body

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INTRODUCTION

Tēnā koutou, tēnā koutou, tēnā koutou katoa

Hawke’s Bay District Health Board is pleased to present its first set of Quality Accounts. The purpose of Quality Accounts is to provide the public with a clear and succinct view of Hawke’s Bay District Health Board’s commitment to continuous quality improvement against a range of measures. The 2013 Quality Accounts do not cover everything we do; the measures within this report were chosen to reflect different aspects of our health system.

Chair Hawke’s Bay District Health Board Co-Chair Hawke’s Bay Clinical Council Co-Chair Hawke’s Bay Clinical Council Chair Consumer Council

The first section outlines three measures reflecting key 2012/13 year local priorities – making sure patients do not have to undertake multiple laboratory tests due to errors in labelling, ensuring that patients are better supported when discharged from our mental health services and that children receive early treatment for sore throats which, if untreated, can lead to acute Rheumatic Fever.

In the second section we measure our performance against the four New Zealand Health Quality and Safety Commission (HQSC) improvement objectives that the New Zealand health and disability sector is collectively looking to improve. No matter where a patient receives treatment in New Zealand they should be safe from falls, receive safe surgical care and not be harmed by medication errors or hospital acquired infections.

The six national health targets are a set of national performance measures specifically designed to improve the performance of health services; they reflect both public and government priorities and provide a focus for action.

In presenting the 2013 Hawke’s Bay District Health Board Quality Accounts we have provided some context to each initiative together with their performance figures. In addition we have identified areas of success and those areas where more work needs to be done. When reviewed in conjunction with our 2013 Annual Report readers will gain an accurate picture of our priorities, progress, investments and determination to continue to improve the health and wellbeing of our community. We are currently developing a Quality and Safety Framework and future quality accounts will reflect the key quality priorities within that framework.

KEVIN ATKINSON CHRIS McKENNA JOHN GOMMANS GRAEME NORTON

Tihei mauri ora

LOCAL QUALITY MARKERS

CORRECT LABELLING OF LABORATORY SPECIMENS CORRECT LABELLING OF LABORATORY SPECIMENS Why is this important? Why is this important? For a number of years diagnostic test errors, especially failure to adequately label or identify correct patient samples, appear as one of the most frequent events reported through our event reporting system. As a result of these errors patient tests are not processed, patients need to have a repeat test undertaken and there may be a small risk to patients of being incorrectly treated. A focus on this quality marker will lead to fewer repeat tests being required which is safer and more convenient for patients and less waste of time and resources.

For a number of years diagnostic test errors, especially failure to adequately label or identify correct patient samples, appear as one of the most frequent events reported through our event reporting system. As a result of these errors patient tests are not processed, patients need to have a repeat test undertaken and there may be a small risk to patients of being incorrectly treated. A focus on this quality marker will lead to fewer repeat tests being required which is safer and more convenient for patients and less waste of time and resources.

What has been achieved? What has been achieved? Over the past 12 months we have introduced new acceptance/rejection criteria which have resulted in fewer issues and less repeat testing for our community laboratory partner (Southern Community Laboratory). However, diagnostic test errors continue to be a significant problem for the hospital laboratory; which indicates the difficulty in implementing sustainable change in an acute hospital environment. We will continue our focus on this quality marker and target those areas with the highest error rate.

Over the past 12 months we have introduced new acceptance/rejection criteria which have resulted in fewer issues and less repeat testing for our community laboratory partner (Southern Community Laboratory). However, diagnostic test errors continue to be a significant problem for the hospital laboratory; which indicates the difficulty in implementing sustainable change in an acute hospital environment. We will continue our focus on this quality marker and target those areas with the highest error rate. The results The results

Labelling errors ‐ Hospital  Labelling errors ‐ Community 

Number/ 

Date Number/ 

Date 

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PLANS WHICH REDUCE THE RISK OF RELAPSE IN PEOPLE WITH MENTAL ILLNESS Why is this important? Relapse prevention plans (RPP) are developed for people with enduring mental illness because research shows that these are effective at improving outcomes if they are maintained. High rates of “up-to-date” RPP are an indication of service responsiveness and reliability.

What has been achieved? The target for the year was 95 percent completion and we have seen a consistent improvement since October 2011 when only 24.1 percent of people with enduring severe mental illness had an up to date plan. In the final quarter of the 2012/13 year up to date plans were in place for 87.5 percent of children and youth aged under 19 years, with plans in place for 75.8 percent of Māori children and youth aged under 19 years. For adults, the result was 93.1 percent for the total population and 87.1 percent for the Māori population. There has been significant and steady progress in the use of RPP for both the total population and for Māori patients. We are continuing our ongoing focus on this service performance measure and expect to meet targets next year.

The results

 

 

Percentage of people with enduring severe mental illness who have an up to date relapse prevention plan Baseline

As at January 2012

Target 2012/13

Actual As at 9th July 2013

0-19 years Child & Youth

Total 47.3% ≥95% 87.5% Māori 40.0% ≥95% 75.8% 20 years and over Adults (excluding addictions)

Total 77.7% ≥95% 93.1% Māori 60.1% ≥95% 87.1%

 

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RHEUMATIC FEVER Why is this important? New Zealand has high rates of rheumatic fever (RF) among Māori and Pacific people; rates that are usually seen in third world countries. Hawke’s Bay has always had one of New Zealand’s highest rates of notified RF with a particular concentration recently in the Hastings suburb of Flaxmere. Since October 2010, a multi-faceted, locally developed inter-agency campaign ( Te Taiwhenua o Heretaunga, Presbyterian Support Family Works, Housing NZ) began to address this problem by offering throat swabbing and prompt treatment for those with streptococcus throat infections in local Flaxmere schools. Together with our community partners we then link young people and whānau into programmes that address contributing environmental factors such as household overcrowding, damp and cold homes.

What has been achieved? Within Hawke’s Bay in 2012/13 everyone who had a positive swab was treated well within the targeted limit of five days. In addition, provisional information1 for Hawke’s Bay shows that rate of acute RF hospitalisations has reduced from 4.3 per 100000 to 2.6 per 100000 for the year to June 2013. Eradication of acute RF is now a national objective within the Government’s “key results areas” for New Zealanders. Continuing to reduce hospitalisations for acute RF will show that our prevention work – both in identifying risk and in assisting communities to address the environmental causes – is being successful.

The results

   

Rheumatic Fever hospitalisations 

Rate per 100,000 

Note: in the table above for the period October 2012 – June 2013 no one waited more than five days for treatment following a positive swab.

1 Ministry of Health, provisional data. August 2013.

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NATIONAL QUALITY MARKERS

REDUCE HARM FROM FALLS Why is this important? Falls are common amongst elderly and especially those living in the community or hospitalised with acute illness. The ‘Reducing Harm from Falls’ programme was established by the Health Quality & Safety Commission (HQSC) with the aim of reducing harm to people as a consequence of falling – especially older people receiving care. Harm from a fall can change a patient’s life – it is the number one reason for admission to aged residential care. No national target has been set for these markers; however we are aiming to achieve 100 percent.

What has been achieved? There are two quality markers that focus on measures that can reduce the risk of harm from falls in adults receiving care in hospital.

1. The percentage of hospital patients aged 75 years or older (or 55 years or older if Māori or Pacific) who have been assessed for their risk of falling. In Hawke’s Bay Hospital in February 2013; 86 percent of these patients had a falls risk assessment during their hospital stay. Regular quarterly audits will be reported to the HQSC from July 2013.

2. The percentage of patients in the age groupings mentioned above who have been identified to be at risk of falling, and who then had an individualised care plan put in place. In February 2013 in Hawke’s Bay, 75 percent met this requirement.

Strategies that reduce the risk of falling include: 1. A multi-disciplinary Falls Minimisation Committee meets quarterly to review falls event data and develop action plans to address identified issues. A regional meeting ensures there

is a consistent and targeted approach to reducing the risk of harm from falls, including use of falls 'signalling tools' such as bed pad sensor (detect patient movement) and patient alarms, alert signage in patient notes, and on room entry doors, were successfully trialled in two wards. These will be more widely implemented over the coming year. Staff education sessions on the impact of falls injuries have occurred and will be repeated in future as the need arises.

2. We have invested into falls minimising equipment such as ‘invisibeams’ (alerting staff when an ‘at risk’ patient attempts to get out of bed), floor level beds which reduce the risk of injury if vulnerable patients fall out of bed, and personal monitors when a vulnerable patient is attempting to get out of bed unaided.

Hourly rounding by nursing staff is another recently introduced initiative that (through increased nurse to patient contact time) has been proven to reduce the risk of harm to patients from falling. This has been trialled in two ward areas where falls have occurred more frequently in the past and a significant reduction in the number of falls has been demonstrated. We will now roll out this initiative to all adult inpatient areas.

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REDUCING HARM FROM SURGERY Why is this important? Adverse events are those which may result in serious harm or death to patients and in the context of surgical procedures may include events such as surgical items (such as swabs) left inside a patient. In these instances a further operation or procedure is required to remove the item and an increased hospital stay and risk of infection.

The ‘Reducing Perioperative Harm Surgery’ programme aims to improve the quality and safety of health care services provided to patients undergoing surgery in hospital. It focuses on preventing adverse events through the use of a ‘Surgical Safety Checklist’. This checklist was developed by the World Health Organisation to encourage teamwork and to ensure the correct surgical procedures are carried out on the correct patient. It has three components that align with different stages in the ‘surgical journey’ for patients. The first of these is the ‘check in’ component which requires the whole theatre team to meet about the procedure and check before the patient is sedated that everything needed for the surgery to proceed is available and ready to go. The second component is called ‘time out’ and confirms that all correct surgical team members are present, understand each other’s roles, and are prepared for surgery. The third, and final component is the ‘sign out’ section which is used to ensure the patient is adequately prepared before leaving the operating room.

What has been achieved? A baseline audit in February revealed that only 35 percent of checklists were completed in their entirety (ie all the components of all three steps) at Hawke’s Bay Hospital (‘check in’ – 61 percent, ‘time out’ – 80 percent, and ‘sign out’ only 38 percent). Since this time, the Perioperative service, led by their Quality Review Team, has intensified their focus on the use of this critical safety tool, shared results with staff, educated staff and carried out regular monitoring. This has led to a significant improvement in achievement of the required standard. A follow up audit confirmed improvement with 79 percent completion of the three step checklist. Thorough use of the checklist will continue to remain ‘under the spotlight’ in the Perioperative service’s quality action plan through the use of ongoing weekly audits and quarterly reporting to HQSC will commence from July 2013 with the aim of achieving the national target during 2014.

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REDUCE HARM FROM MEDICATION Why is this important? The Medication Safety Programme aims to reduce harm from medication errors that can inadvertently occur to patients in hospital (eg patients receiving the wrong drug). The aim of the patient medicine reconciliation programme is to ensure hospital teams are fully aware of medication the patient was taking before admission to hospital. This is achieved by accurately documenting patients’ medications on admission.

What has been achieved? Our local target is that 40 percent of all medical and surgical patients will have a medicine reconciliation completed within 24 hours following admission. Hospital pharmacists have a pivotal role in the achievement of this standard as a key requirement of their role is to identify medicines discrepancies for hospital prescribers to correct. A baseline audit in June 2012 saw 29 percent achievement of this standard. Subsequent audits have demonstrated a gradual improvement with monthly results ranging 38 – 62 percent (averaging 45 percent July 2012 – June 2013). At least two thirds of patients do have their medicines reconciled at some time during their hospital stay – we have exceeded our marker for the last five months. The following patient story illustrates the worth of medicine reconciliation.

Mary was admitted into hospital and her insulin was prescribed as 74 units in the morning and 55 units at night. But she was usually on 22 units in the morning, 30 units at midday and 22 units at night. The doctor and the nurse looking after Mary did not know this and Mary couldn’t speak English. Before the medicine reconciliation was completed, Mary was given 74 units of insulin in the morning. Her blood sugar level went very low and she became dizzy and unwell. If the medicine reconciliation had not been done Mary may have experienced more episodes of very low blood glucose and could have gone into a coma. Mary is also usually on calcium carbonate twice a day, which is used to bind extra phosphate in her body as she has chronic kidney disease. This was prescribed for only once a day. If medicine reconciliation hadn’t been done, her blood phosphate level may have increased which could have caused joint and tissue damage.

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REDUCE HARM FROM HEATHCARE ACQUIRED INFECTIONS Why is this important? Healthcare associated infection is one of the most common adverse events in health care worldwide (eg chest infection, wound infection). Up to 10 percent of patients admitted to modern hospitals in the developed world acquire one or more infections and compromise patient care and recovery. Hand hygiene has been recognised as the single most effective strategy to prevent the spread of infection. A national hand hygiene work programme has been implemented and applied locally, monitored through regular observation audits of hand hygiene practice (“Five Moments for Hand Hygiene”) by clinical staff.

What has been achieved? As at June 2013, HBDHB was achieving above the 70 percent target set by Hand Hygiene New Zealand at 73 percent. Contributing to this result is the ongoing commitment of a small dedicated team of trained auditors, ongoing visibility and support of infection prevention and control personnel, and availability of educational material through static displays and online learning tools. Another key focus of infection prevention has been on the management of central venous lines in intensive care units (ICU). A central venous line is a catheter (placed into a large vein in the neck, chest or groin) used to administer medication or fluids, obtain blood tests, and assess cardiovascular health. Being inserted through the skin, there is a possibility that infection may occur as a result.

A national project to reduce rates of central line associated bacteraemia (CLAB) in ICUs sought to reduce CLABs in ICUs from a baseline of 3.32 per 1000 line days to less than one per 1000 line days. This “Target CLAB Zero” initiative has enabled all DHBs to work together using a multi-disciplinary approach to apply best practice for preventing central line infections and to standardise a way of measuring them.

Through the hard work of the HBDHB’s ICU staff, our CLAB rate was 0.5 per 1000 line days in 2012/13 (with the last recorded case in November 2012). This project (using best practice guidelines) is in the process of being rolled out into the wider hospital. The areas involved will collect data to monitor compliance of care and to report on the occurrence of CLAB.

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NATIONAL HEALTH TARGETS

Health targets are a set of national performance measures specifically designed to improve the performance of health services. The targets are determined by the Minister of Health and reviewed annually to ensure they align with government’s health priorities. Three of the targets focus on patient access, and four focus on prevention. The health targets provide a focus for action, and the impact the targets make can be measured to see how they are improving health for our population: Results for Hawke’s Bay in the 2012/13 year are:

alth services. The targets are determined by the Minister of Health and reviewed annually to ensure they align with government’s health priorities. Three of the targets focus on patient access, and four focus on prevention. The health targets provide a focus for action, and the impact the targets make can be measured to see how they are improving health for our population: Results for Hawke’s Bay in the 2012/13 year are:

0%

20%

40%

60%

80%

100%

120%

Q1 94% 106% 100% 87% 98% 52% 61%

Q2 94% 110% 100% 92% 100% 56% 65%

Q3 93% 112% 100% 94% 99% 91% 67%

Q4 93% 117% 100% 95% 98% 80% 72%

Target 95% 100% 100% 85% 95% 90% 75%

Shorter stays  in ED

Improved access  to Elective 

Shorter waits  for Cancer Treatment

Increased Immunisation

Better help for Smokers  to 

Quit Hospitals

Better help for Smokers  to Quit Primary 

More Heart and Diabetes  

Checks

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Shorter stays in emergency departments The national target is that 95 percent of patients will be admitted, discharged, or transferred from an Emergency Department (ED) within six hours. The target is a measure of the efficiency of flow of acute (urgent) patients through public hospitals and home again. This is a challenging target to achieve as like all EDs across New Zealand, we are seeing growth in ED attendance that exceeds our population growth. A number of initiatives have been introduced to improve performance against this target such as increasing medical staffing presence during times of increased demand, opening additional ‘winter beds’ for the two peak winter months, relocation of some medical day cases from the Acute Assessment Unit to Villa 6 and looking at our overall hospital discharge processes.

Improved access to elective surgery In the 2012/13 year we planned to provide an increased number of patients with elective services. Pleasingly against the Hawke’s Bay target of 5,729 we achieved 6,599 (an increase of 15 percent or 870 additional people). Achieving this result involves many people working collaboratively and in coordinated manner across the organisation including outpatients, surgical booking, surgical procedure and patient care teams,

Shorter waits for cancer treatment This target aims to ensure people who require cancer treatment should receive either radiation oncology or chemotherapy within four weeks. For Hawke’s Bay people cancer treatment is provided as a regional service through MidCentral DHB. Achieving our 100 percent performance against this target relies on effective coordination, efficient booking and referrals and good patient management and confirms people are receiving cancer treatments as early as possible.

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Increased immunisation The target for the 2012/13 year is that by July 2013, 85 percent of eight-month-olds will have their primary course of immunisation (at six weeks, three months and five months) on time. This target increases to 90 percent by July 2014 and 95 percent by December 2014. Hawke’s Bay has eclipsed the national target with 94.3 percent of all infant immunisations and 95.7 percent of our Maori infants had by eight months of age received their immunisations on time. This level of coverage and consistency of performance is due to our well-coordinated and targeted immunisation services across the health sector.

Better help for smokers to quit – Hospital and Primary Care Smoking related disease is the single most preventable illness affecting our population. This target aims to have 95 percent of patients who smoke and are seen by a health practitioner in public hospitals and 90 percent of patients who smoke and are seen by a health practitioner in primary care offered brief advice and support to quit smoking. For patients in hospital there has been a steady improvement against this target since it was introduced, achieving 98.5 percent in the last three months of the 2012/13 year. Within primary care (ie general practice) a huge amount of effort has seen a significant performance lift from 47.3 percent at the start of the year to 79.6 percent by year end. Ongoing focus should see the target consistently reached in 2013/14.

More heart and diabetes checks This target is especially important for Hawke’s Bay because of our focus on improving the management for people with long-term conditions and improving Māori health. The target is that 90 percent of the eligible population will have had their cardiovascular risk assessed in the last five years (to be achieved in stages by 1 July 2014). The first stage was to achieve 60 percent by July 2012, and then 75 percent by July 2013.Two comprehensive public campaigns by Health Hawke’s Bay PHO encouraging people to have heart and diabetes checks has seen performance lift from less than 60 percent at the start of the year to 72.4 percent by year end. While short of the target efforts to improve performance will continue, particularly for our Māori and Pacific populations.

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OUR FUTURE FOCUS In future years we will continue to focus attention on our performance against the national health targets and the Health Quality and Safety improvement objectives. These markers provide the overall New Zealand population with consistent performance assessment measures for key patient safety and quality of care indicators. In future years we will continue to focus attention on our performance against the national health targets and the Health Quality and Safety improvement objectives. These markers provide the overall New Zealand population with consistent performance assessment measures for key patient safety and quality of care indicators.

In addition, and in collaboration with our community health providers, we will focus on measures which are important to our local community and which have been identified by the Hawke’s Bay Clinical Council as key indicators of local service improvements which will lead to improved quality and safety of our hospital and community health services. In addition, and in collaboration with our community health providers, we will focus on measures which are important to our local community and which have been identified by the Hawke’s Bay Clinical Council as key indicators of local service improvements which will lead to improved quality and safety of our hospital and community health services.

We know that Hawke’s Bay is home to some of the most vulnerable populations in the country and addressing issues of repeat and long term hospital presentations, ensuring equitable access to mental health services, reducing the level of non-attendance at outpatient appointments and continuing to identify, support and intervene where family violence is evident will be key areas of focus.

We know that Hawke’s Bay is home to some of the most vulnerable populations in the country and addressing issues of repeat and long term hospital presentations, ensuring equitable access to mental health services, reducing the level of non-attendance at outpatient appointments and continuing to identify, support and intervene where family violence is evident will be key areas of focus.

In addition the design and implementation of agreed clinical pathways for people with long term conditions (eg diabetes) will benefit from key performance indicators which monitor the quality of the care received by patients and improvements in health outcomes. In addition the design and implementation of agreed clinical pathways for people with long term conditions (eg diabetes) will benefit from key performance indicators which monitor the quality of the care received by patients and improvements in health outcomes.

In this way we can confidently present our annual quality accounts as a snapshot reflection of a sector which works together, celebrates its successes yet is equally not afraid to put the spotlight on those areas it believe it could do better. And in doing so we can be justly proud of the quality and safety of the services we deliver. In this way we can confidently present our annual quality accounts as a snapshot reflection of a sector which works together, celebrates its successes yet is equally not afraid to put the spotlight on those areas it believe it could do better. And in doing so we can be justly proud of the quality and safety of the services we deliver.

This is our first annual Quality Report and we welcome feedback, comments and suggestions. This is our first annual Quality Report and we welcome feedback, comments and suggestions.

Hawke’s Bay DHB Quality Accounts 2013 feedback can be emailed to: ceo@hawkesbaydhb.govt.nzHawke’s Bay DHB Quality Accounts 2013 feedback can be emailed to: ceo@hawkesbaydhb.govt.nz

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APPENDIX 1: QUALITY MARKER DASHBOARD Quality marker Quality marker Target Target Actual (2012/2013 latest result) Actual (2012/2013 latest result) 1 1 Specimen labelling – hospital Specimen labelling – hospital - - No improvement 2 Specimen labelling – community laboratory - Improving 3 Relapse prevention plans 0-19 yr Total 95% 87.5% 4 Relapse prevention plans 0-19 yrs Māori 95% 75.8% 5 Relapse prevention plans 20 yrs+ Total 95% 93.1% 6 Relapse prevention plans 20 yrs+ Māori 95% 87.1% 7 Rheumatic fever – waiting more than 5 days for treatment of throat infection 5% 0% 8 Falls risk assessment completed 100% 86% 9 If at risk of falling Individualised care plan in place 100% 75% 10 Surgical safety checklist 100% 79% 11 Medicine reconciliation withn 24 hrs admission 40% 45% (average 2012/13 year) 12 Hand hygiene compliance 70% 73% 13 Central line associated bacteriaemia <1 per 1000 line days 0.5 per 1000 line days 14 Shorter stays in ED 95% 93% 15 Improved access to elective surgery 100% 117% 16 Shorter waits for cancer treatment 100% 100% 17 Increased immunisation 85% 95% 18 Better help for smokers to quit – hospital 95% 98% 19 Better help for smokers to quit – primary care 90% 80% 20 More heart and diabetes checks 75% 72%

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