The following summary has been accepted by the Ministry of Health as being an accurate reflection of the Surveillance Audit conducted against the Health and Disability Services Standards (NZS8134.1:2008; NZS8134.2:2008 and
NZS8134.3:2008) on the audit date(s) specified.
The Southern District Health Board (SDHB) includes a number of sites and for the surveillance visit the Invercargill based Southland Hospital, the Queenstown based
Lakes District Hospital, and the Dunedin based
– Wakari Acute and Forensic Mental
Health and Addictions Services, the Disability Service and the Dunedin Hospital were all visited. The SDHB is responsible for providing health services to the
304,260 people living in its district. The DHB provides medical; mental health & addictions and intellectual disability; older persons and community; surgical; women, child and public health and clinical support services.
Consumer Rights
All patients and family members spoken with report that they receive services in accordance with the Health and Disability Commissioner’s Code of Health and
Disability Services Consumers’ Rights (the Code) and as ordered by the court, for those requiring secure special care admitted under the Intellectual Disability
Compulsory Care and Rehabilitation Act (IDCC&R) and the Mental Health Act. This includes being treated with respect and receiving good explanations with both verbal and written information used. Staff are sighted providing professional care to patients. In the medical area, a patient with a communication disability, reports that staff have provided very good communication and ensure their understanding of investigations and care. Interpreter services as available and known to staff.
Two areas for improvement identified at the last audit related to patient visual and auditory privacy in the day of surgery unit (Dunedin) and the recording of patients’ cultural and spiritual needs in the maternity services and the paediatric ward
(Dunedin). No changes have been made since the last audit and these remain areas requiring improvement. Additionally privacy issues have been identified for the mental health service areas that require improvement. Two additional areas raised related to consumers not being consistently informed of rights and documenting this in their clinical file. An issue previously identified for mental health seclusion remains open but is raised within the restraint standard.

The organisation has an open disclosure policy that is implemented.
The organisation has a district wide complaints policy known to staff interviewed.
Information on how to make a complaint is displayed and provided as part of an admission pack. Patients are aware of how to make a complaint and one family member gave an example of how they were supported in the process. The complaint has been attended to quickly and satisfactorily. The Code of Rights in poster and brochure format, information brochures on the Nationwide Health and
Disability Advocacy Service and information on Patient Affairs services (that support patients and families), are sighted in all areas visited. Complaints are part of the quality improvement reporting and a new electronic process is being implemented to ensure more robust reporting.
Organisational Management
The Southern DHB (SDHB) Vision: Better health
– better lives – whanau ora is accompanied by the “Southern Way” principles. There is a draft Southern DHB
Health Profile which will underpin the strategic planning 2015-2020 process. SDHB has been through significant organisational change over the past 18 months with a new structure implemented at the executive level and the establishment of the provider division directorates. These directorates have a leadership team which reflects a clinical/management partnership approach.
A new quality and risk management system has been implemented based on zero patient harm. It has a fourfold aim to improve: the health of the Southern population, the patients’ experience, the efficiency of the DHB, and learning opportunities for staff. A key element has been the establishment of the “performance excellence and quality improvement strategy” which provides a foundation for quality and performance activity.
Areas for improvement raised at the last audit remain for policies and procedures maintenance and document control systems.
Alignment of quality monitoring activity to the quality system has improved however requires further work to complete. For example the linking of information gained from audit activity and data collection including linking information from Lakes
Hospital. The complaints register provides information to the quality team however the data is still not collected in a systematic manner making it difficult for analysis and trending. There is a data base for recording the management of adverse events including a robust process for investigating Severity Assessment Code (SAC) One and SAC 2 events. Two areas for improvement remain open related to quality monitoring and one for incident management.
Good progress has been made with corrective action planning and the risk management system. These two areas now meet the standard. The teams are

looking forward to the pending implementation of a new incident management system during 2014 which will integrate the programme elements and assist with analysis and reporting.
The Human Resource department has been managing the change associated with the organisation-wide structural review during 2013 and building the culture of the organisation. Improvement is needed with some of the human resource systems and policies, including mandatory training, performance appraisals and management of personnel files. Medical staff credentialing and the nursing and midwifery professional development recognition programme are well established.
Staffing levels and skill mix are being reassessed with the use of a nursing acuity system and the care capacity demand management programme. SDHB also has an occupancy information system which identifies the numbers of patient’s in each ward and their length of stay. Areas for improvement are to have a formal documented escalation pathway for times when demand exceeds resource along with an ability to meet requests for short term and long term leave relief at Dunedin Hospital.
There are concerns with clinical records storage in Dunedin Hospital including health and safety issues. Privacy of patient files in the outpatient department in
Invercargill, and the location of computer screens in the medical wards at Dunedin
Hospital mean that patient information is visible in the corridor. In mental health services the detail included in the record is inconsistent for evaluation to occur.
These are areas for improvement.
Continuum of Service Delivery
Nine patient journeys were followed through medical, surgical, mental health, maternity and paediatric services across the DHB. This, along with additional sampling of files, found that the delivery of care is provided by suitably qualified staff.
Coordination of care across services is well managed with the exception of Coronary
Care Unit where work is in progress to improve care coordination, and in management of paediatric patients who have not been admitted under the under the paediatric team. These areas require further improvement.
Assessments completed inform the interventions required for patients, however family violence screening assessments are incomplete in a number of areas and this requires improvement. The planning of nursing care is also an area that requires further development in all services visited, with deficiencies noted in the level of detail, identification of goals, and maintenance of updated nursing plans to reflect the changing needs of patients. The provision of detailed care plan and monitoring to meet all the assessed needs of the patients has been identified as an area requiring improvement in mental health services.

In general, patients interviewed were complimentary about the services they were receiving.
Transfer planning is undertaken for both in hospital and inter hospital transfers but the documentation and communication between hospitals and staff members for patients being transferred across the district is an area that requires further improvement.
Comprehensive evaluation of care occurs throughout the service in a timely manner.
Health records are of a high standard and record timely care. Observation records are comprehensive and where early warning score tools are utilised, these are well completed. Where progress is different from expected the services are noted to respond appropriately.
Multidisciplinary team meetings are used to update care and facilitate discharge planning. Discharge planning is generally well done with the exception of the surgical, mental health and paediatric areas, where this needs further development.
Mental health services have progressed a number of developments to improve the electroconvulsive therapy (ECT) programme. An ECT clinical record audit needs to be undertaken in order to fully address the previous area identified for improvement.
Improvements in medicine management processes are occurring across the DHB.
Predominantly, the introduction of the electronic prescribing and medication charts, the establishment of a District Medicines Committee and plans to align policies and procedures across the district. These are noted to significantly address previous areas requiring improvements. There are still improvements needed in the clinical documentation of prescribing, administrative procedures and monitoring of storage temperatures for medications. Processes for self-administration of medicines met the required standard.
Food services are provided from the Dunedin Hospital kitchen and provide for the daily preparation of meals across the district including Southland Hospital and a number of other DHB managed facilities. Monitoring of food, fridge and freezer temperatures is evident in the kitchen but does not occur consistently at ward level where the responsibility lies with clinical staff. Improvements are required to ensure that patient’s dietary allergies are communicated to the kitchen staff, and that food fridges in clinical areas are monitored for temperature. Patients commented on the good quality of the food provided.
Safe and Appropriate Environment
All Southern DHB buildings have current building warrant of fitness, the relocation of the children’s’ inpatient unit and the neonatal intensive care unit have certificates of public access awaiting sign off for the changes .

Approved fire service evacuation plans are in place and evidence of planned fire drills for all areas is sighted.
Each hospital has their own databases for biomedical equipment and Dunedin has records for electrical and general equipment. There is a planned preventative maintenance programme (PPM) based on legislative and/or manufacturers requirements. Reports are generated to show compliance against the plan. There is evidence of critical equipment meeting the requirement however other equipment is sighted at both hospitals in use in clinical areas without a current maintenance sticker. This is an area for improvement from the last audit and remains open.
The monitoring of hot water temperatures was an area for improvement at the last audit and there is an annual plan for testing, however, this remains an area for improvement as no documented evidence of action taken and retesting of areas where the temperature is high in patient care areas.
A number of areas for improvement identified at the last audit included; the availability of personnel protective equipment, checking of an emergency trolley, availability of a personnel alarm system in the psycho geriatric ward, and ensuring the external contracted laundry service meeting the requirements of the laundry standards. These areas are seen as now meeting the requirements of the standard.
One area identified at the last audit continues to require improvement and this relates to the toilets and showers in the orthopaedic ward being problematic for this patient group.
There has been considerable improvement in Intellectual Disability Services to meet the corrective actions at the 2013 certification audit and they are to be commended.
Work on improving observation in the bedrooms of residents in the Helensburgh cottage is still in progress. Access to the secure out door area remains restricted and dependant on staff availability.
Restraint Minimisation and Safe Practice
Work is being undertaken to align approval processes for the management of restraint and an advisory group has been established to support the development of contemporary systems. A review of the Restraint Minimisation and Safe Practice
(RMSP) policies, procedures and guidelines has been completed. A flowchart and education packages have been developed.
A new restraint care plan has been introduced and includes an assessment of the patient prior to restraint being considered. Enablers and ‘minders’ are used in order to minimise the need for restraint. Staff are receiving education on the new processes. This is yet to be fully implemented so remains an area for improvement.
There is ongoing high use of seclusion and restraint across both mental health services. Strategies are being developed for the Dunedin and Invercargill sites in

conjunction with the district wide Seclusion and Restraint Minimisation Governance
Group. There is variance in the detail in treatment plans and in the detail recorded for nursing monitoring when people are in seclusion, particularly where they have complex needs. Evaluation of seclusion and restraint utilisation in mental health remain areas for improvement.
The Risk Committee collates restraint and seclusion events at Wakari intellectual disability and mental health services on a monthly basis and these are analysed for trends and recommended actions reported.
Infection Prevention and Control
The Infection Prevention and Control District Quality Plan includes details of the surveillance programme and guides the assessment and procedures for screening.
Staff report the infection control committee provides advice and support across the district. The results of the surveillance programme are discussed at infection control meetings and actions are undertaken to eliminate or minimise any infection control barriers or issues identified through the monitoring and surveillance process.
Monitoring processes include blood stream infections, multi-resistant organisms and surgical site infections. Patient risk assessments are seen to be performed on admission for multi-drug resistant organisms.
A district wide antimicrobials committee has been established to support the aligning of processes to ensure antibiotic usage is monitored and appropriate. Reference material and guidelines are available to support prescribers regarding availability, prescribing and list of restrictions in place for all the antibiotics available for use within the DHB. The medicines review committee is in discussions with pharmacy staff as to the most appropriate method to ensure the guidelines and indications for antimicrobial use meet current best practice. A review of antibiotic usage and compliance against guidelines occurred towards the end of 2013, and the recommendations are currently being addressed. The previous area identified as requiring improvement has now been addressed and meets the standard.
The Infection Prevention and Control District Quality Plan includes details of the surveillance programme and guides the assessment and procedures for screening.
Staff report the infection control committee provides advice and support across the district. The results of the surveillance programme are discussed at infection control meetings and actions are undertaken to eliminate or minimise any infection control barriers or issues identified through the monitoring and surveillance process.
Monitoring processes include blood stream infections, multi-resistant organisms and surgical site infections. Patient risk assessments are seen to be performed on admission for multi-drug resistant organisms.
A district wide antimicrobials committee has been established to support the aligning of processes to ensure antibiotic usage is monitored and appropriate. Reference

material and guidelines are available to support prescribers regarding availability, prescribing and list of restrictions in place for all the antibiotics available for use within the DHB. The medicines review committee is in discussions with pharmacy staff as to the most appropriate method to ensure the guidelines and indications for antimicrobial use meet current best practice. A review of antibiotic usage and compliance against guidelines occurred towards the end of 2013, and the recommendations are currently being addressed. The previous area identified as requiring improvement has now been addressed and meets the standard.