NHB eNewsletter - June 2011
"Better, sooner and more convenient care from a unified and sustainable public health system."
- From the Chair of the Health Quality & Safety Commission
- From the Director's Desk
- Hayden Wano on primary care and Māori health
- Improving cardiac surgery in New Zealand - Dr Andrew Hamer
- Getting to know you
- Diabetes nurse prescribing -Mary Meendering
- A new Disability Support System
- Health Workforce New Zealand: Workforce Service Reviews
- National Health IT Board: Sector working together to reduce medication errors on the front line
- Regional Service Plans update
- About this Newsletter
From the Chair of the Health Quality & Safety Commission
Like many other countries, New Zealand has found itself challenged by a recent economic downturn. Our health and disability system stands up well to most international comparisons, but maintaining, and indeed improving on, the high standards New Zealanders expect is increasingly challenging.
The Health Quality & Safety Commission was established in November 2010 to lead quality and safety improvements in the health sector. The Commission's establishment was an important part of Government's response to maintaining and improving the standard of health care for all New Zealanders. In doing this, there is a clear expectation, and an obvious need, for the Commission to work closely with other organisations within the system, notably the National Health Board. A shared aim is therefore of fundamental importance.
The Commission's Board and the National Health Board have collaborated on developing a common view of the need to pursue quality and efficiency within the limitations of the available resources. Starting from the Triple Aim promulgated by the Institute of Healthcare Improvement in the USA, we have come up with a New Zealand version of this approach.
The New Zealand Triple Aim
Between us, we have agreed to work collaboratively towards simultaneously achieving the following three outcomes:
- improved quality, safety and experience of care
- improved health and equity for all populations
- best value from public health system resources.
Continuing good work
Several excellent projects had been started by the former Quality Improvement Committee. It clearly made sense for the Commission to continue this momentum, and to push forward with ensuring that these projects deliver value for the money already invested in them. Work underway includes the development of a medicines reconciliation process; the introduction of a nationally standardised medication chart; a focus on reducing hospital-acquired infections; and the introduction of a programme to improve consumer participation.
In each of these projects we are working closely with the Ministry of Health and the National Health Board, including the IT Board and Health Workforce New Zealand, to ensure that the investment of time and money involved in each is coordinated, efficient and effective.
One example of this collaboration is the work underway with the National Health Board, the National Health IT Board and others to implement ambitious changes to the way medications are prescribed, dispensed and monitored in our hospitals and in primary care. Medication errors are an ongoing and potentially serious cause of patient harm and the ultimate aim of this work is a series of well-integrated and functional electronic systems for prescribing, reconciling and tracking medications.
Another example is the input the Commission is having into the establishment of a New Zealand Centre of Excellence in Health Care Leadership, established by Health Workforce New Zealand and hosted by the University of Auckland.
New projects
As we explore new initiatives, including a coordinated programme to reduce surgical site infection (incorporating hand washing and central line infections), work to reduce falls, and responses to reports from our Mortality Committees, we will continue to work with consumers, managers, funders, policy makers and the wider community to maintain and improve the excellence of our health and disability services.
To find out more about the Commission and our work programme, visit www.hqsc.govt.nz, and register on the site to receive regular updates about quality and safety news and issues.
Professor Alan Merry, Chair, Health Quality & Safety Commission
From the Director's Desk
I would like to update you about two important pieces of work the National Health Board has been assisting Southern DHB to manage in recent weeks.
An NHB team is carrying out a joint assessment of systems at Dunedin Hospital with the Southern DHB and assisting the Southern DHB to engage with the Wakatipu community over the best future model for health services in that area.
The joint assessment of Dunedin Hospital is being progressed by a panel including National Health Board Service Improvement Manager Jill Lane, Ministry of Health Chief Nurse Jane O'Malley, Canterbury DHB Professor of Emergency Medicine Dr Mike Ardagh and Capital and Coast DHB Forensic Psychiatrist Greg Young.
The team is making good progress and at this stage is looking at the end of July to provide recommendations to the Southern DHB.
The Wakatipu Expert Panel is being led by the immediate past Chair of the NZ Medical Association Dr Peter Foley. The other two members are well-known consumer advocate David Russell and a position shared by Dr Angela Pitchford Emergency Physician, and Professor Mike Ardagh.
The panel is making good progress having met with stakeholders in the Wakatipu Area and held a public meeting. It has a full engagement programme which it will work through during the coming weeks.
The Southern DHB will consider the recommendation of the Wakatipu Expert Panel at its August Board meeting and implementation could begin in September.
It is good to see the NHB working positively with a DHB to extend its capacity through additional expertise and providing an independent and fresh set of eyes.
Once again please spare a thought for the health and disability sector in Canterbury as the area continues to be rocked by aftershocks in the onset of winter. I am certain you will continue to keep them in your thoughts and assist wherever is practical.
Chai Chuah, National Director
Hayden Wano on primary care and Māori health
Hayden Wano is of Te Atiawa, Taranaki and Ngati Awa Iwi descent. He has more than 10 years' nursing experience, followed by more than 20 years' experience in health management. Hayden is currently Chief Executive of Tui Ora Limited (a Māori development organisation) and General Manager of Iwi and Community Midland Health Network.
Hayden has been a member of the National Health Board since its inception in 2009. Here he discusses his two strongest passions, primary care and Māori health.
I see a lot of synergy between the Better, Sooner, More Convenient (BSMC) and emerging whānau ora policies. The trick is in how we implement these policies in a way that delivers integrated services across the system. This is a challenge for the whole system.
There are opportunities in primary care and Māori health to reduce fragmentation and improve service integration for the benefit of patients and whānau. However to achieve this we also face many challenges.
Māori health providers are a relatively new part of the sector, most only having been around for the past 10 to 20 years. Further work has to be done to develop Māori health capability.
Some of the qualities Māori health providers have brought to the sector, where it is working well, include improved access for communities that have typically not been effectively engaged by the system. This part of the sector has also shown itself to be willing to try new ways of service delivery through innovation.
Unfortunately many of our Māori health providers are vulnerable to workforce shortages and issues around financial sustainability, as is the wider system. There is a compelling need to adapt to more sustainable business models to provide effective, high-quality, high-performing services that are integrated into the wider system.
Whānau ora creates the opportunity to address some of the wider determinants of health through cross-Government initiatives. Ultimately this will be good for high-needs communities and whānau by making the whole system more responsive, but of equal importance, enabling whānau to taking greater responsibility for their own health needs.
If we have a system that improves health outcomes for Māori and high needs populations, then we will have a system that will be good for everyone.
Hayden Wano, NHB Board Member
Improving cardiac surgery in New Zealand - Dr Andrew Hamer
Improved access to cardiac surgery has reduced patient waiting times to levels never achieved before. The National Cardiac Surgery Clinical Network has worked with the National Health Board (NHB) and District Health Boards (DHBs) throughout New Zealand to help achieve this.
The Network was developed to lead and oversee reform of the New Zealand cardiac surgical system and improve the delivery of cardiac surgery. It was formed following concerns about ballooning waiting times and access to cardiac surgery in New Zealand. This concern saw a range of recommendations made by the Cardiac Surgery Service Development Working Group and the Government. The Network was established by the Minister of Health in April 2009 to lead the reform of New Zealand's cardiac surgical system and to improve the delivery of cardiac surgery in New Zealand.
The initial challenge facing the Network was to provide surgery for the backlog of patients on waiting lists around the country. Under the guidance of the Network, DHBs developed recovery plans to ensure these patients got the surgery they needed as soon as possible.
Significant progress has been made in increasing the volume of cardiac surgery operations, improving the geographic equity of cardiac surgery provision, enhancing the effectiveness of clinical prioritisation, and reducing the number of patients waiting for surgery.
"Thanks to the efforts of the Network, significant progress has been made in shortening the patient journey so that patients are assessed and treated more quickly," says National Clinical Leader Dr Andrew Hamer.
"From lengthy and distressing delays for cardiac surgery, New Zealanders now have a public cardiac service to be proud of. We can be confident that those in need are able to access them,"
"This success presents us with new opportunities to consolidate our gains and further improve the system."
Much of this future work will be undertaken by a newly formed New Zealand Cardiac Network which encompasses a wider range of stakeholders including the National Cardiac Surgery Clinical Network, the four regional cardiac networks, the Cardiac Society, NZ Heart Foundation, primary health care and the Ministry of Health.
Dr Hamer says the New Zealand Cardiac Network will oversee and co-ordinate a work programme that focuses on the entire cardiac care pathway to ensure people have the access to the care they need. It will build on the achievements of the National Cardiac Surgery Clinical Network and drive further improvements to ensure better access to cardiac care for those who need it.
"We need to make sure that other parts of the cardiac patient journey work as smoothly as possible, and I look forward to being involved in this work."
Getting to know you
Most people only go to see their GP or practice nurse when something goes wrong - an upset stomach, a sore foot, a chest infection.
The problem with that traditional approach is that health professionals often have limited information to form a true picture of the patient and to plan their care accordingly.
At Amesbury Health Centre, in Palmerston North, they realised that there isn't enough time in a 15-minute consultation to really get to know patients - so they did something about it.
They began inviting older patients, aged 75 years and up, to the centre for a free hour long sit-down with a practice nurse.
Jane Ayling, a nurse who worked on the project, says it was astonishing how much they learned about those patients - many of whom had been coming to the health centre for a decade or longer.
"We thought we knew them really well from that long-term interaction, but we found out an incredible amount about them - their physical activity, what happens in their homes, their diet, their transport needs and more," she says
"Based on that information the practice nurse (in consultation with the patient and sometimes with a GP) works out an individualised care plan for each patient."
'Charlie' (not his real name) - is in his 70s and has been a regular at Amesbury for some years. Like many others, his interactions have been brief, focusing on his needs when he felt unwell.
"This assessment was very informative for me as a patient. I never realised I could do so much more to improve my health," Charlie says.
In line with the care plan, he's now taken up some light physical activity, and foresworn the slice of cake he used to have each day for afternoon tea.
The initial trial has now turned into a process of nurse-led care plans which is being rolled out across 42 GP practices in the MidCentral area. Amesbury is now doing the assessment on all new patients aged over 75 who have known long-term illnesses.
Read more case studies in Better, Sooner, More Convenient Health Care in the Community (PDF, 912KB)
Diabetes nurse prescribing - Mary Meendering
The diabetes nurse prescribing demonstration, established by Health Workforce New Zealand in collaboration with the New Zealand Society for the Study of Diabetes, involves extending the role of diabetes nurse specialists to allow them to prescribe a range of medications for their patients.
For the past 15 years Mary Meendering has been working as a clinical nurse specialist, caring for people with diabetes across every age group and condition, from children, adolescents, women in pregnancy, and adults with type 1 diabetes, to those with complex type 2 diabetes.
As one of the newly designated diabetes nurse prescribers at MidCentral DHB (one of four demonstration sites), Mary has found her role is already increasing her job satisfaction. "Professionally I have the skills and knowledge to safely prescribe and I also have the support from colleagues and clinical supervisors for this project. The benefits to my patients are clear: it will help to reduce barriers for many who would otherwise need to see their GP for a prescription - it will improve the health outcomes for my patients."
If there is a significant change in a patient's diabetes status, they will still need to see their GP or specialist. If not, however, nurses like Mary will often be the best person to monitor a patient's condition, help them manage it and provide routine prescriptions.
A typical day varies, with newly diagnosed children or gestational diabetes patients taking priority. "I organise my own nurse-led clinics and attend the routine paediatric, young adult clinics and the high-risk antenatal/diabetes combined clinic. Phone assessments, crisis intervention and clinical management are a large part of the work as well."
Mary's interest in diabetes has developed over time, stimulated by psycho-social as well as complex clinical aspects. When the opportunity to become a designated prescriber diabetes nurse came up, Mary applied. "It's a fascinating area of practice and I am inspired by many of my colleagues who are passionate about caring for people with diabetes."
Having completed her Master of Nursing in 2010, Mary was academically well placed to take part in the project. She believes postgraduate education in subjects such as pharmacology and patho-physiology is essential to underpin knowledge and clinical decision-making confidently and safely. "I think it is essential to have a sound understanding of the drugs we use in practice. The support of the clinical sponsors and physician supervisors has strengthened relationships within the team and we work well as colleagues."
With the extended role Mary can benefit from the recognition of her expertise and knowledge and she enjoys the learning and clinical discussion with case reviews. "I find it rewarding professionally to be continually expanding my knowledge. Professionally I think that the ability to prescribe will grow the relationships we have with general practitioners and pharmacies. I am hopeful it will also remove some of the frustrations that a delay in treatment changes or delay in getting basic repeats can represent for patients."
A new Disability Support System
The Disability Support Services Group within the National Health Board has developed a new model for supporting disabled people in New Zealand. This is being demonstrated in the Western Bay of Plenty/Tauranga during 2011 in conjunction with the local community.
Over 100 stakeholders attended a powhiri to launch the project, which included disabled people, their families, local Maori and members of the Pacific community.
Anne O'Connell, Group Manager Disability, says listening to what disabled people want is essential if we want to get good outcomes for them and their families.
"Disabled people and their families have told us that the current disability support system doesn't work well for many of them. They have clearly identified that they want increased choice and control over the services they receive as well as flexibility in how these services are delivered.
Anne says it was great to see so many people interested in what we're doing.
"Getting community support and participation is crucial for this demonstration project to work. The people who are directly affected will help us test and refine the new model."
A Local Working Group was set up and in April a National Reference Group has been established. The National Reference Group will enable disabled people and disability organisations to provide strategic input during the planning and implementation of the demonstration project and the development of the new model.
Programme Leader, Jenny Moor, said that it was vital to work closely with disabled people, families/whanau, carers and services to share ideas and to together develop the model further and test it well in the demonstration.
The new model disability support system has four components:
- a stronger focus on Information and personal assistance using local area coordination
- allocation of funding rather than services including an increased self-assessment
- increased choice and control over what support is purchased including expanding individualised funding and making services more flexible
- stronger accountability arrangements for the Ministry, providers and disabled people.
Click here for more information about the new model
Health Workforce New Zealand: Workforce Service Reviews
The government has confirmed some austerity measures across a range of portfolios in this year's budget, and although health continues to be a priority, we still need to face the reality of doing more with less. An increasing focus on productivity and innovation in health will be key.
The workforce service reviews, led by senior clinicians, were tasked with proposing scenarios that will meet our service and workforce needs into the future. The reviews are not intended to be a definitive view of the particular specialty, but to create a platform for further discussion, testing and analysis.
The first six full reports in aged care, eye health, gastroenterology, musculoskeletal, anaesthesia, and palliative care are now available to view on our website.
The next steps include synthesising the recommendations from the reviews and demonstrating some of the new and enhanced roles put forward, providing solutions to productivity challenges while creating new career opportunities.
We are encouraging feedback on the reviews from across the sector over the coming months and will host a national meeting of senior stakeholders from DHBs, colleges, education, professional and patient associations in Wellington in August to build on the outputs of the reviews and consider their implications for future workforce planning.
We will also be working closely with the National Health Board (NHB) to ensure workforce planning and development is fully aligned with the planning of clinical services, continuing to focus on this through 2011/12.
As with any large scale change process, some of the recommendations emerging may be contentious. However, we know the status quo is not an option and the reviews have provided a courageous and creative vision of a future that is not only sustainable, but better for staff and better for patients.
National Health IT Board: Sector working together to reduce medication errors on the front line
A number of activities to reduce medication errors are underway across the health sector. They include electronic and paper based projects.
These activities are all part of the Medication Safety Programme and, at a national level, are the collective responsibility of the National Health Board, National Health IT Board and the Health Quality & Safety Commission.
The programme is overseen by a strategic governance group, and supported at an operational level by a steering group that manages project implementation.
Health Quality & Safety Commission Chair, Professor Alan Merry, chairs the Medication Safety governance group. The group currently includes representatives from the National IT Health Board, the Health Quality & Safety Commission, National Health Board, PHARMAC and the DHB Chairs/CEO group.
Paul Cressey is the Interim Chair of the steering group, which includes representatives from the National Health IT Board, Health Quality & Safety Commission, MedSafe, PHARMAC, DHB chief medical officers, primary care, clinicians and consumers.
Along with lead clinicians, stakeholders and the National Information Clinical Leadership Group, the steering group makes up the delivery arm of the programme. It has the operational oversight and accountability for the following medication safety initiatives that make up the eMedicines programme.
- Community ePrescribing Service
- Hospital ePilots at Southern, Taranaki, Counties Manukau and Waitemata District Health Boards covering:
- eMedicines reconciliation
- eMedicines charting (prescribing and administration)
- pharmacy management/supply
- New Zealand Universal List of Medicines
- NZ Medicines Formulary.
The programme will also play an active role in relation to the medicines components of a range of sector initiatives such as eReferrals, eDischarge summaries, clinical data repositories and shared care.
The paper-based projects are:
- national adult medication chart
- medicine reconciliation.
Elizabeth Plant, Chief Pharmacist, Taranaki District Health Board says medication errors have the potential to cause serious patient harm. "Medication safety programmes have been proven to greatly reduce these errors".
"This is why key stakeholders in the health sector are working together in the interests of patient safety", states Graeme Osborne, IT Board Director. "60% of the value of the Electronic Health Record the National Health IT Board strategy aims to develop comes from improved Medications management".
For more information about the eMedicines Programme, please contact Shayne Hunter on 021 688 440 or email at shunter@medication.org.nz. For more information about the national adult medication chart or medicine reconciliation, see www.hqsc.govt.nz, or, in the first instance, contact Carmela Petagna on (04) 816 4447 or email at Carmela.petagna@hqsc.govt.nz.
Regional Service Plans update
Regional Service Plans (RSPs) from the Northern, Midland and Central regions are now with the Minister of Health awaiting approval. The South Island draft RSP will be considered in July once further details are received.
All four regions have received final feedback on their RSPs and are now focussed on defining their performance management reporting arrangements and progessing agreed actions as identified in their 2011/12 regional implementation plans. Each region will use the performance management framework that they have developed to report progress on their identified priority areas to regional decision making groups and individual DHB Boards. The NHB will also use these as the foundation for discussions with regions that will occur on a quarterly basis as part of its performance monitoring role.
NHB Acting Director Planning and Analysis, Michael Johnson, says "The next step is to work closely with the DHBs to ensure progress is made on the actions that they have identified, with the expectation that regions will make measurable progress in their identified priority areas in 2011/12."
Michael says in addition, "To showcase the intended benefits of regional collaboration and RSPs, we have started an e-booklet which we hope will be ready for release in July.
"We are also now doing some early thinking on the next steps for next year's RSPs. This has come up already in discussions with DHBs, and we will work closely with them over the coming months to further develop and enhance the regional collaborative agenda."
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