Auckland District Health Board
Current Status: 29 April 2014
The following summary has been accepted by the Ministry of Health as being
an accurate reflection of the Certification 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.
General overview
Auckland District Health Board (ADHB) is responsible for providing health services to
the 450,000 people living in its district, along with tertiary services to the greater
Auckland and Northland region and a range of national services to New Zealanders.
Approximately 50% of the patients using ADHB services come from other district
health boards (DHBs). ADHB provides adult medical, cancer and blood, adult
community and long term conditions, cardiology, surgical, perioperative, women's
health, children's health, mental health and clinical support services. The mental
health service was not included in this audit.
Audit Results as at 29 April2014
Consumer Rights
The Health and Disability Commissioner’s Code of Health and Disability Services
Consumers’ Rights (the Code) is displayed throughout the organisation in English
and Te Reo Maori on posters. There are multiple languages brochures available
containing rights information and how to access advocacy services. Patients are
informed of their rights, to ask questions, give informed consent and make a
complaint and opportunity to provide feedback on the quality of service through the
ADHB website forum. Staff have education on informed consent, advocacy, the
complaints process, privacy and confidentiality and spoke of how they incorporate
the Code into every day practice.
Privacy is protected and care is provided in a manner which is responsive to, and
respectful of, the cultural and spiritual needs of patients and their families. Patients
and their families are not subjected to discrimination. Patients spoken with stated
their rights are upheld, staff give respectful service and they are made aware of the
Code and advocacy support. They stated that they have good communication with
staff throughout the patient’s hospital stay. Paediatric and maternity patients are
supported to have an advocate present. Of note is the new initiative to support
partners to stay overnight in the Tamaki Ward. Links with families and communities
are supported. In the medical services area, family involvement is welcomed where
this is desired by the patient and, at multidisciplinary meetings.
Improvement is required to ensure patients are provided with information and
opportunities for discussion about any resuscitation decisions. Patients’ carers in the
paediatric wards report that their consent is gained where this is appropriate to do
so, although verbal consent is not always recorded, and this also requires some
improvement.
There is a complaints management process that meets the requirements of the
standard. This is known to staff in the clinical areas. There is a complaints data
base managed by the consumer liaison team leader. This records the timeframes
and the actions taken against each complaint. Complaints are reported through to
each of the service directorates on a monthly and quarterly basis. If areas of
concern or negative trends are identified these are also reported to the quality
manager.
Organisational Management
ADHB has a vision of ‘healthy communities, quality care’, and has articulated the
direction and goals for the Annual Plan. ADHB is one of four DHBs in the Northern
region which have a range of shared activities, including a Northern Regional Health
Plan - 2012, which describes how the DHBs can work together to meet future
demand. ADHB also works closely with Waitemata DHB including having two
shared executive level roles focussed on the achievement of improved health
outcomes and the funding allocation to achieve this goal.
During 2014 ADHB is embarking on an extensive strategic planning process to
refresh the vision, mission and values and strategic goals. This process will include
involvement of the wider community, service users and staff.
In 2013 ADHB underwent a senior management restructure with the provider
directorates now having a ‘single point of accountability’. A clinical director works in
partnership with senior clinical leaders supported by management, patient
effectiveness and human resource team members. The management operating
system is becoming well embedded and is leading to tangible improvements in
service quality and productivity.
The DHB uses the Annual Plan as the quality and risk plan with a focus on the
patient experience. A commitment to this is seen through the on-line patient
experience survey introduced in 2012. This survey has a database of over 12,000
responses providing a wealth of information to guide quality improvement activity.
There is an established structure and system for the management of quality and risk
which includes reporting to the senior management team, the Clinical Board and the
Hospital Advisory Committee. ADHB is a signatory to the ‘Open for better care
programme’ of the Health Quality & Safety Commission (HQSC) and is monitoring
priority areas such as falls prevention, medications management, hand hygiene,
surgical safety, hospital acquired infections and pressure injuries.
Adherence to the document control system, and ensuring policies and procedures
are current are areas requiring improvement as is having sufficient resource
available to facilitate the timely response to adverse event investigation, monitoring
and resolution.
Staffing levels are adequate for the clinical professions and the ‘releasing time to
care’ programme is resulting in an increase in nursing direct patient contact time.
The implementation of an acuity system has been accepted as a priority plans are
well underway for rollout commencing during 2014.
The human resources system handles approximately 10,000 staff with a turnover of
less than 10%. There is excellent service specific orientation to the different
specialties. Medical staff credentialing is up to date. Areas requiring improvement
relate to the system for management of the personnel files, and for monitoring
completion of induction, staff training and annual performance appraisals.
Patient records are scanned into an electronic record within 48 hours of discharge
making information available, however improvement is needed with the management
of the hardcopy file during the inpatient period to support ready access to
information, to ensure no loose pages are lost from the file and to protect privacy.
Continuum of Service Delivery
Assessment commences in the emergency department (adult or child) or the adult
assessment and planning unit (APU) using a structured assessment format which
follows the patient through to discharge. A variety of assessment tools are available
for use which are designed to identify the needs of the patient and inform the plan of
care. Assessment continues throughout the admission. Areas requiring
improvement have been identified for midwifery assessment, and the utilisation and
completion of assessment templates within the child and women’s health service.
Care planning is individualised and well documented with some inpatient areas
utilising care pathways. Care needs are communicated through shift handover
processes and documented in progress notes. There is timely access to all services
and it is demonstrated that planned interventions are implemented and are linked to
the assessment processes, and referrals are actioned. Multidisciplinary teams
contribute to the planning and coordination of care, with improvement required in the
paediatric service.
Patients and family members report that staff discuss care planning and goals with
them, however improvements are required in relation to the documentation of
individualised patient’s goals.
Ongoing evaluation of patient responses to the care provided occurs and is
documented in the progress notes by all members of the health care team, at least
every eight hours, and is of a high standard in most instances. An ‘early warning
score’ is being used to identify if the patient’s condition changes and this is
communicated in a timely manner and changes to care are efficiently and promptly
implemented. Improvements are required with the completion of the paediatric early
warning score, the monitoring of individual patient’s fluid intake and the completion of
the surgical safety checklist.
Discharge planning commences early in the hospital stay, with timely referrals made
as required. Discharge from inpatient services occurs when all aspects of the
discharge plan are in place and there is a team view that the patient is adequately
prepared for discharge. Patients and family members report being actively involved
in their discharge planning. Discharge documentation is available to support the
planning process and is generally well documented, however an area for
improvement has been identified within the child and women’s service.
Medication management is guided by policies, procedures and guidelines which are
seen to be in line with good practice and known to staff through orientation to their
area of work. Two medication safety committees (children and adult) oversee the
medication processes including managing medication reconciliation. A number of
areas are identified as requiring improvement related to medication management
and documentation. Examples are prescribing practices, safe pro re nata (PRN)
prescribing and management of when patients bring their own controlled drug into
hospital.
The food services have undertaken Hazard Analysis and Critical Control Point
(HACCP) with few recommendations. The menu is on a two week cycle with
multiple variations (200), these are overseen by dietitians. Special diets and
requirements are managed by service dietitians and processes are in place to inform
the kitchen staff.
Safe and Appropriate Environment
All buildings have a current building warrant of fitness. Seismic status for all the
buildings is known with some buildings closed pending strengthening.
There is an effective maintenance information system with staff spoken with stating
that response to maintenance requests is good. Areas requiring improvement
include some of the carpet and seating in public areas; and shower wall panelling
that needs repair in certain clinical areas.
Biomedical equipment records indicate a high degree of compliance with monitoring.
The high risk life support equipment monitoring is an area for improvement as is the
monitoring of hot water temperature at the patient point of contact.
Auckland DHB (ADHB) has policies on waste management systems that are
comprehensive and include personal protective equipment (PPE). An external
contracted company manages waste. The availability of PPE in the maternity and
paediatric areas needs improvement.
A tour of the facility to review compliance with environmental standards identified
areas requiring improvement related to hand washing facilities on one dock way,
storage of chemicals in a few areas, medical and cytotoxic waste storage and
HAZCHEM signage for the underground diesel tank is missing.
The cleaning service for all buildings is now in-house and satisfaction with the new
arrangements is reported by clinical area staff. The laundry service is provided off
site by an external contracted company. Audit of the provider occurs on an annual
basis with no issues raised by staff in the clinical areas.
ADHB has comprehensive emergency and incident management systems in place
including plan documents that specify roles and responsibilities and readily available
flip charts for rapid response guidance. Current fire evacuation approval and six
monthly fire drills evident.
Security systems include restricting entrance points at night and responses to
breaches of security or aggressive behaviour. The security system in the maternity
service requires improvement.
Restraint Minimisation and Safe Practice
A restraint minimisation group meets quarterly and receives reports on restraint and
enabler use. There is no consumer member on the committee and this is being
looked at. Audits occur monthly with results analysed and trends identified by the
clinical effectiveness co-ordinator for review by the committee. The restraint
minimisation policy is under review.
Following incidents where patients fell over the bedrails while in use as a restraint or
enabler a project has been undertaken to review all aspects of bedrail use. This has
resulted in an improved decision making process to both identify if bedrails are the
most appropriate way to manage the patient’s risks and to monitor their safe use.
The generic forms pertaining to restraint are on the intranet. These capture the
assessment, review and monitoring of restraint use. Neuroservices have
documentation specific to the patient needs in their service.
Three patient’s charts, where restraint has been used are reviewed, two in the
neuroservices area and one in a medical ward. It is identified that the forms do not
fully meet the requirements of the standard and the documentation for the patient in
the medical ward lacks detail in assessment and evaluation. These are areas for
improvement.
Infection Prevention and Control
There are mature infection prevention and control processes in place and evidence
that these are imbedded within the organisation. Responsibilities are defined with
clear lines of accountability to senior management. A team of well qualified infection
prevention and control practitioners lead a programme developed and signed off by
the Infection Prevention and Control Committee.
Education of staff is planned to meet the needs of the organisation and this is
completed at orientation, on an ongoing basis, such as the hand hygiene work, and
online education is also available.
There are a number of projects underway, and one looking at a new process for the
management of multidrug resistant organism – extended spectrum beta lactamase
(ESBL) patients - is in the pilot project phase and this is tracked as a systems tracer
as part of the audit process. There is evidence of education and planning of the
process and follow up management by the infection control co-ordinator for the area.
Surveillance is undertaken and reported nationally, regionally and in-house.
Antimicrobial stewardship is undertaken and monitored.