NHB eNewsletter - September 2011

"Better, sooner and more convenient care from a unified and sustainable public health system."

• From the Chair: Sally Webb, Capital Investment Committee
• From the Director's Desk
• An exciting time for nurses - Mary Gordon
• DHB Success Story: Wairarapa DHB's novel approach to improving medication safety
• Dedicated elective surgery environment reduces costs through increased productivity
• New, improved hearing aid services
• Support for Canterbury DHB earthquake recovery measures
• New tools for primary care management of type 2 diabetes
• Emergency preparation pays off for World Cup
• Quality & Safety Challenge 2012
• Health Workforce New Zealand update
• National Health IT Board update: Great response to Clinicians' Challenge 2011
• About this Newsletter

From the Chair: Sally Webb, Capital Investment Committee

The Capital Investment Committee makes recommendations to the National Health Board, Director-General and Ministers of Health and Finance on DHB capital proposals. 

Late last year we issued new guidelines for capital approvals for DHB development.  A number of proposals to be assessed under the guidelines were received by the beginning of February around the time the Christchurch earthquake struck.

The earthquake caused uncertainty around whether substantial emergency capital investment would be required to keep the Christchurch health system functioning and, as a result, the capital round for 2011 was suspended.

To help the Canterbury health system, the Ministers of Health and Finance approved a Capital Investment Committee recommendation to approve and fund a $16m project to bring general medicine patients back to Christchurch hospital.  Since February, these general medicine patients have been split between Christchurch and the Princess Margaret hospitals.  We undertook to fast track the approval, meaning the new arrangements will be in place by winter 2012.

Canterbury DHB has also been carrying out detailed invasive seismic investigations of all its buildings.  As a result of the investigations we are ready to consider any emergency capital proposals (not covered by insurance) at short notice.

As well our Committee considered a number of business cases which were in the pipeline including:

Other DHBs that had submitted proposals for the 2011 capital round have been very understanding of the extraordinary circumstances which forced the suspension of this year's capital round.  These 2011 proposals, along with any other new proposals, will be considered as part of the 2012 capital round.  We need new proposals to be submitted to us by 31 January 2012.

Our new capital guidelines are focussed much more on DHBs showing they are implementing innovative models of care which will reduce the need for capital investment. This avoids a situation where DHBs find themselves making a substantial capital investment, incurring increased interest and depreciation costs, where in turn they would have to reduce spending on other services to meet the increased costs.

The Capital Investment Committee is putting emphasis on ensuring new models of care have been appropriately explored, and that any proposed models are credible and achievable.

Our guidelines put considerable emphasis on a regional approach to capital.  What we expect for the four DHB regions (Northern, Midland, Central and South Island) is to look at their capital plans over their region for the next decade, and prioritise them based on affordability.  We have met the Chairs and CEOs of two regions to discuss these expectations and will meet with the other two regions over the next few months.

The Committee's other emphasis is to explore capacity options in the private sector.  It may be that private hospitals and other providers have spare capacity, or could develop more for public services, thereby reducing capital needs.  When capital proposals are considered, we will explore these options with private providers and DHBs.  We also expect to see private funding options have been considered.

Sally Webb, Acting Chair

Capital Investment Committee

From the Director's Desk

The end of November 2011 is a significant time for the National Health Board in signalling the direction and priorities for the health and disability sector for the next few years. 

We are currently working on several pieces of work which will converge to help do this.

With the General Election there will be a need for the Ministry of Health to brief an incoming Minister (BIM) of Health.  The BIM provides an opportunity to take stock of progress that has been made so far and advise on the emphasis for the next period. 

This thinking also has to be reflected in very practical ways in our preliminary four year Budget material and in the DHB planning guidelines.

The government is looking at its four year Budget strategy and asking us to show the budgeting that will provide the health and disability support services that they are looking for.  This will involve careful consideration of where further efficiencies can be made, what new developments are priorities, and where and how services can be better integrated and aligned to be more effective.  This thinking in turn will provide the framework for the guidance for Annual and Regional Services plans that is issued to District Health Boards in the planning package.

To take advantage of this work we have to get on with planning next year's activity while remaining sufficiently flexible to respond to changes in emphasis or the introduction of new elements or even a whole new programme that may result from the General Election. 

The National Health Board's commitment is to be as open and prompt in keeping you informed of how any changes might impact on the sector.

Chai Chuah, National Director

An exciting time for nurses - Mary Gordon

National Health Board Member Mary Gordon has been Executive Director of Nursing at Canterbury DHB since 2002. Mary began her nursing career in the 1980s, and moved into health management roles in the 1990s, undertaking further education in management, public health, health economics, public policy, and health education and promotion.

Here Mary discusses how nursing roles have changed significantly in recent years and how nurses are well placed to help shape a quality, sustainable future health service.

Wherever there's a health service, you'll usually find a nurse making a difference by being part of the service delivery team. Nurses are flexible and quickly able to adapt where and how they work.

For a long time nurses didn't have a career pathway that kept them close to the patient, but there's been enormous progress on this in recent years, and there are now tremendous opportunities for nurses at the clinical bedside level. Nurses are stepping up to these roles and we're seeing the benefits.

I look at our Nurse Specialists - our Nurse Educators, Nurse Practitioners and Charge Nurses - and see the benefit this investment in post-graduate education has made to patient care. They're constantly looking at ways to improve things.

I'm also extremely proud of the relationships we have with our education providers, both at undergraduate and post graduate level. They are committed to making sure nurses are well prepared to be able to take on these new roles.

Many DHBs, including Canterbury, have invested in advance health assessment, pharmacology, and speciality training for their nurses, and ensured those skills are transferable across hospital, primary and community care.

In Canterbury, the earthquakes have meant we've had to reconfigure how we deliver some health services, and many nurses have found that a very positive experience. In some cases, it has opened up new career paths for them.

For instance, because we lost a large number of residential aged care beds, we've had to find new ways of providing care for more people in their homes. Rest home level care can be provided for patients with complex needs by nurses with advanced health assessment skills. Even without a post-earthquake environment, services such as these play an important role in meeting the national health priority of improving the health and independence of older people.

New Zealand is in a really good space to address the challenges our health sector faces, in particular, our aging population and demand for health services outstripping supply. It's one of the few countries in the world that doesn't have a shrinking health budget.

I recently observed at our assessment centres for new nursing graduates and was extremely impressed by their high level of skills, their great attitudes and their absolute enthusiasm for nursing.

Every challenge also presents an opportunity and New Zealand's nurses have a great opportunity to help shape the future of our health services.

Mary Gordon, NHB Board Member

DHB Success Story: Wairarapa DHB's novel approach to improving medication safety

When Wairarapa DHB began using the National Medication Chart this month, clinicians had already improved their prescribing habits, thanks to an innovative programme by the DHB's nurse educators.

"We were aware of some poor prescribing habits which we didn't want carried over to the new medication chart," says Clinical Nurse Educator, Lucy McLaren.

"They included handwriting not being clear, the number of units not being clear, times not being right and allergies not being recorded.  Nurses have to administer the medication and shouldn't have to try and interpret a chart."

She says decimal point placement has also been an issue in the past. "2.5 can look like 25. The decimal point is pre-printed on the new chart so there should be no confusion, and each letter of a drug name has to be printed within lines, so we wanted to get everyone in the habit of recording the information in the way it would be done on the new charts.

"We knew that some nurses felt they didn't always feel supported to challenge poor prescribing, so this was also an opportunity to address that," says Lucy.

The nurse educators took 10 key elements from the new medication chart and nursing staff were advised that unless all 10 were included in a chart, medication would not be administered.

Once a month, the nurse educators donned red 'prescription monitor' T-shirts and conducted random checks on prescriptions. Their presence was also a reminder to nursing staff that they had support to insist the new standards were adhered to.

"We also chased up prescribers we had particular concerns about and reported back concerns to our Chief Medical Officer to follow up."

Another innovation has seen junior doctors working at night auditing each other's medication charts against the new standards.

"When the workload eases in the early hours they can do a few charts each. Getting it right now is good professional practice for the rest of their careers."

Lucy says the response to the new measures was generally very positive.  "It clarified good prescribing practice ahead of the introduction of the new medication chart, and gave doctors an opportunity to ensure their prescribing practice met the standards.

"In some cases doctors had to amend a medication chart written by another doctor. But we kept the focus on patient safety, clarified the prescription so the medication could be administered, and then we'd go back to the original prescriber and talk to them."

The new national medication chart is one of a number of activities to reduce medication errors across the health sector. It's part of the Medication Safety Programme which is the collective responsibility of the National Health Board, National Health IT Board and the Health Quality & Safety Commission. The implementation of the paper-based national medication chart, in conjunction with medicine reconciliation, lay the foundations for the move towards electronic solutions. 

Dedicated elective surgery environment reduces costs through increased productivity

A Waitemata District Health Board (DHB) pilot programme to deliver fast track elective surgery in a dedicated environment has achieved extremely promising results, with more operations performed, lengths of stay reduced and high levels of staff and patient satisfaction.

The pilot, originally only for hip replacement surgery, was established in April 2010 at the under-utilised Waitakere Hospital. But its success has seen the programme extended to include general, ear, nose and throat, urology and gynaecology surgery, with more than 20 surgeons and 20 anaesthetists now working at the hospital.

Waitemata DHB Head of Surgery and Ambulatory Services, Mr John Cullen, says the pilot model of care features a number of new concepts.

"We've created dedicated surgeon, anaesthetist and nurse teams. Small, consistent teams mean more predictable surgery times and a more productive use of operating theatres."

Remuneration of surgeons and anaesthetists is linked to productivity through an alliance contracting arrangement. "This means all the parties come together to talk about how we can save money," says John.

Surgeons have full responsibility for pre, post and in-hospital patient care, including doing ward rounds. "No junior doctors are employed and ward nursing staff have direct access to surgeons for patient care, which is much more efficient."

A number of patients (up to four) who are having the same procedure are placed on the same theatre list, and then share a room to facilitate nursing and rehabilitation.

John says theatre and ward nursing staff do an excellent job of preparing patients well so that they know what to expect from the new approach.

"Patients like it too. They tell us they like being in the same room as other people who've had the same surgery, and they enjoy having a closer relationship with their surgeon."

The new model of care has achieved a 17 percent reduction in costs for knee replacements and 12 percent for hip replacements.

John says it will be one of the models of care considered for the new, $39 million, state-of-the-art Elective Surgical Centre (ESC) Waitemata DHB is building at its North Shore Hospital site.

The ESC (due for completion in 2013) will have 40 beds and four operating theatres and is expected to perform nearly 6,000 operations a year, approximately 25 percent being additional operations than previously achieved.

As a specialist elective surgery centre treating only non-emergency cases, the ESC will reduce patient waiting times and increase the number of elective surgery procedures by streamlining pre-and post-surgical visits, including patients receiving an appointment for surgery during their consultation.

John says the ESC is an opportunity to "be bold and make significant changes" to the way elective surgery is delivered.

"You don't get a chance like this very often. This is an entirely separate and free standing hospital, and this is the time to do it because change within an established structure is very difficult.

"Everyone agrees that things need to change if health care services are to be sustainable, and with the right model of care and a purpose-built Centre, we're confident we can achieve even greater cost savings."

Clare Perry, Manager of Electives, National Health Board says there is evidence to show that separating elective and emergency surgical streams reduces waiting times, achieves better workflows and improves productivity. The model at Waitakere Hospital is being watched with interest. 

New, improved hearing aid services

The Ministry of Health has introduced a new scheme designed to improve hearing aid services around New Zealand.

Development Manager, Disability Support Services for the National Health Board, Sue Primrose, says previously the Ministry has had no formal arrangements with audiologists or audiology providers.

Sue says, as of 1 July a new scheme has been brought in, effectively introducing multi-provider contracts.

"This is a completely new arrangement that sets out the requirements for those providing hearing aid services to people eligible for Ministry of Health funding."

The Hearing Aid Services Notice 2011 sets out the terms and conditions under which audiologists and audiology providers can claim the hearing aid subsidy and apply for hearing aids for people who have hearing loss.

Sue says the new scheme will be an improvement for people who receive funding for hearing aids.

"One of the reasons for the new scheme is to make sure people who receive funding for hearing aids get access to better information about the type of hearing aids that may meet their needs."

Following a formal tender process, Accessable was selected to manage these services nationally on behalf of the Ministry. The new Hearing Aid Services combine all previous funding arrangements which were operated by the Ministry of Health - the children's hearing aid fund, the hearing aid subsidy and hearing aids funded through the Equipment and Modification Services.

The new hearing aid service now has two funding schemes:

• Hearing Aid Funding Scheme - which covers the price of hearing aids for eligible adults and children, and
• Hearing Aid Subsidy Scheme - which provides a subsidy of $511.11 per hearing aid for eligible adults.

Eligibility for hearing aids has not changed significantly since new criteria were introduced in March 2010, however some minor changes have been made:  

• funding for hearing aids for adults is not available more than once in a six-year period
• funding for hearing aids for children under 16 years (or up to 21 years if in full time study) is available no more than three times in a six-year period.

Accessable is working with all key groups to implement a system which will be efficient and cost-effective.  Plans for the future include an on-line application system for audiologists to use and the establishment of a sector group so that they can get feedback about the new service and work with the sector to make any changes or improvements.

Support for Canterbury DHB earthquake recovery measures

The National Health Board's (NHB's) Capital Investment Committee has approved two projects that will help Canterbury DHB take further steps to recovery. 

The Capital Investment Committee (a sub-committee of the NHB), was established to develop a new centrally-led process for the national prioritisation and allocation of health capital funding. 

After the earthquakes, as a short-term solution, the Canterbury DHB relocated medical services from Christchurch Hospital to Princess Margaret Hospital.

As part of a broader earthquake recovery plan, the DHB proposes a number of integrated initiatives to enable most of the components of the acute medical service to be moved back onto the Christchurch site by winter 2012.  The initiatives include a larger, well located Acute Medical Assessment Unit.

To allow the return, the current Outpatients Department will first be moved to the St Asaph campus across the road from Christchurch Hospital, with additional procedure rooms which will provide the space for the new acute unit.

The new acute unit will help primary and secondary care to work together with a change in the model of care as the unit will take direct referrals from GPs and will have community service liaison staff on site to assist with discharge.

New tools for primary care management of type 2 diabetes

Primary care health professionals have new, easy-to-use tools to help them identify and manage patients with type 2 diabetes.

The new resources were commissioned by the Ministry of Health and have been published by New Zealand Guidelines Group (NZGG), working with the Ministry and experts in the management of diabetes from across the health sector.

 NZGG is an independent, not-for-profit organisation that promotes the use of evidence in the delivery of health and disability services.

Primary care health professionals will be able to use the new resources to identify patients at high risk of complications, manage raised blood pressure and improve blood sugar level control, including being guided on when to start insulin.

The relationship between diabetes and cardiovascular disease (CVD) has long been recognised, and for a significant proportion of people, the two conditions co-exist. People with type 2 diabetes are two- to- four times more likely to suffer from CVD, and CVD is the leading cause of death in people with diabetes.

Health Targets are a National Health Board priority. The Health Target of better diabetes and cardiovascular services aims for more eligible adults to have their cardiovascular disease (CVD) risk assessed; more people with diabetes to have their free annual checks, and of those people, more to have satisfactory or better diabetes management.

The Ministry of Health's National Clinical Director Diabetes and member of the NZGG Diabetes Advisory Group, Dr Brandon Orr-Walker, says the tools will help health practitioners better identify and manage patients with type 2 diabetes.

"Diabetes is a very significant disease, and its prevalence is rising at a rate that is exceeding population growth. It's estimated that there are nearly 200,000 New Zealanders diagnosed with diabetes - predominantly type 2 diabetes. Additionally there may be some tens of thousands who have diabetes but have not yet had it diagnosed. The prevalence of diabetes in Māori, Pacific and South Asian populations is around three times higher than Europeans.

"These tools were developed to address three priority areas identified by the Guidelines expert team. They will help health providers identify people at the highest risk of diabetes-related complications and provide health professionals with practical advice to manage raised blood pressure, achieve better glucose control, and manage early signs of diabetes kidney disease with the best possible care and treatment. They have been developed to encourage proactive management."

At the heart of the new resources are quick reference guides that contain 'decision trees' to guide practitioners in their decision-making on, for example, initiating insulin therapy.

There are also training materials to assist primary health care trainers and educators to train others in managing type 2 diabetes, including a set of 10 online clinical question-and-answer scenarios, which GPs and nurses can use to test their understanding of the new guidance, as part of an online learning programme endorsed by the Royal New Zealand College of General Practitioners.

Emergency preparation pays off for World Cup

The National Health Board (NHB) Emergency Management Team has been a part of the Government's planning and preparation of Rugby World Cup 2011.

The Emergency Management Team is part of a wider cross-Government response to ensure the World Cup runs smoothly. EMT's focus is on protecting the health of New Zealanders and visitors.

Director of Emergency Management, Charles Blanch says, "We're now in a position where the reporting and information sharing systems to deal with any World Cup events that require a response from the health sector are working well. 

"Our reporting systems monitor daily how DHBs across the country are responding to any medical demands associated with the events, and so far the reporting shows that any additional demand on health services has been well managed.

"The preparation has also enabled us to support Auckland Regional Public Health Service (ARPHS) who are managing an upturn in notified Measles cases.

The Emergency Management Team is working closely with the Office of the Director of Public Health, Communicable Diseases, Communications and the Immunisation Team to support ARPHS and ensure that the Government and key agencies are briefed, says Charles.

Quality & Safety Challenge 2012

DHBs and others in the health sector are encouraged by the Health Quality & Safety Commission to consider applying for the "Quality & Safety Challenge 2012".

The Commission has established a pool of funding to develop ideas that will improve patient safety, foster quality improvement, and/or improve consumer engagement.

The fund will be open to applications from all health providers and health workers in New Zealand, whether working in the public or private sector, or in non-government organisations.

Proposals must be for activities in the 2011/12 year, although exceptional applications that require funding in part of the 2012/13 year may be considered.

Applications will be called for soon and will close on Friday 28 October, so gather your ideas together!  Email info@hqsc.govt.nz to receive further information as soon as this is available.

Health Workforce New Zealand update

On 24 August Health Workforce New Zealand hosted a stakeholder forum - Partnership and Potential: Towards a 2020 Health and Disability Workforce.

The meeting brought together decision-makers from the health sector to discuss the strategic, cultural and policy changes needed in professional education, training, recruitment and deployment to ensure a sustainable New Zealand health workforce.

Six main themes were selected for further discussion on the day, and participants also identified other areas that need to be pursued further. Among the themes HWNZ has identified (which will be progressed in the coming months) are managed care/care co-ordination and end of life care.

Representatives from across the sector will participate in working groups to further develop and implement the actions identified from the day, many of which are already underway within HWNZ or within the sector. HWNZ intends to support each of the groups.

The time and energy people put into the day was inspiring, and the insight provided on what's important nationally, regionally and locally confirmed that HWNZ priorities are also those of the sector.

Most importantly, the day demonstrated that New Zealand has an extremely committed resource in the people who work in the health and disability sector, whose ideas, innovations, and actions are shaping the workforce needed for 2020.

Skills and Simulation Based Education

HWNZ is in the process of developing a comprehensive national skills and simulation-based education strategy incorporating a network of simulation and skills centres aligned to the four regional training hubs.

There is growing recognition of the role that specific skills and simulation-based education (SSBE) is required to augment the training needs of doctors, nurses and allied health professionals.

SSBE provides an outstanding opportunity to develop inter-professional collaboration and role flexibility, aid the transition from undergraduate education into clinical practice and address gaps in traditional healthcare education.

HWNZ has established an Expert Group, tasked with developing the strategy, which will be supported by a reference group which includes representation from the regional training hubs.  We are undertaking a survey to identify existing facilities, equipment, activities and resources, and also perceived needs including demands for the future to inform the strategy.

National Health IT Board update: Great response to Clinicians' Challenge 2011

Nearly 60 entries have been received for the Clinicians' Challenge 2011. The challenge is run by Health Informatics New Zealand (HINZ), the New Zealand Health IT Cluster (NZHITC) and the National Health IT Board. It gives clinicians the opportunity to put up a work-related IT problem to vendors.

The winning 'problem' is set as a challenge to health IT vendors who propose concepts and solutions. The problem should be important and recurring. It may be a process that needs improving or an enhanced or new way to find, store or share health information.  

The solution must promote better integrated care across the primary and secondary care sector.

Fifty-six problems have been submitted from across the sector, including from hospital specialists, emergency department nurses, GPs, academics, practice nurses and occupational therapists.

The winning entries qualify for study and field trip opportunities.

Both the clinical proposals and the vendor solutions are judged by a panel from HINZ, the IT Health Board, NZHITC, the National Information Clinical Leadership Group, and a health consumer. The winning clinical proposal and vendor solution will be announced at the HINZ Annual Conference and Exhibition in Auckland on 24 November.

The author of the winning case and the winning vendor solution will have the opportunity to visit an existing demonstration site of a health IT solution in New Zealand, Australia or another destination overseas.

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