appendix a.1: nrhp development phase contributors

Appendix A.1:

NRHP Development Phase Contributors

Northern Region Health Plan – May 2013 Appendix A.1 1

Team Member

Me

dic

al

Nu

rsin

g

Alli

ed

He

alt

h

& T

ec

hn

ica

l

Oth

er

Clin

ica

l

Oth

er

Tony Norman XNick Chamberlain XMike Roberts XLester Levy XDale Bramley XAndrew Brant XLester Levy XAilsa Claire XMargaret Wilsher XGregor Coster XGeraint Martin XGloria Johnson X

Nick Chamberlain XMike Roberts XDale Bramley XAndrew Brant XAilsa Claire XMargaret Wilsher XGeraint Martin XGloria Johnson X

Robert Paine XBrett Halvorson XLuke Bunt XJo Brown XRosalie Percival XMargaret White XRon Pearson XPauline Hanna XTony Phemister XSarah Prentice XBarry Vryenhoek XRoss Chirnside X

ADHB

CMDHB

NRA

healthAlliance

Regional Governance Group

REGIONAL GOVERNANCE COMMITTEE

Regional Capital Group

NDHB

WDHB

REGIONAL CAPITAL GROUP

CEO/CMO

NDHB

WDHB

ADHB

CMDHB

CEO / CMO FORUM

NDHB

WDHB

ADHB

CMDHB

DHBs Primary

NDHB Kim Tito XWDHB Debbie Holdsworth XADHB Denis Jury X

Lisa Gestro XBenedict Hefford X

NRA Sarah Prentice X

Mike Roberts XMargareth Broodkoorn XAndrew Brant XJocelyn Peach XPhil Barnes XMargaret Wilsher XMargaret Dotchin XGloria Johnson XDenise Kivell XMartin Chadwick X

CLINICAL LEADERS

NDHB

REGIONAL FUNDING FORUM

CMDHB

Clininal Leaders

Regional Funding Forum

CMDHB

WDHB

ADHB


Michael Roberts X XRobert Paine XDarren Manley XAndrew Brant XLinda Harun XMartin Orr XStuart Bloomfield XRosalie Percival XLinda Wakeling XMargaret Wilsher XGreg Balla XPhillip Midgley XJanet Gibson XGloria Johnston XRon Pearson XMargie Apa X

NRA Sarah Prentice XBarry Vryenhoek XJohan Vendrig X

Karen O’Keeffe (NDHB) X

Jacqueline Ryan X

Peter Leong XDebbie Monigatti X

NDHB Alan Davis X

Andrew Jull XJane Lees XColin McArthur X

Greg Balla XSally Roberts XJocelyn Peach XKim Bannister XPenny Andrew X XGloria Johnson X

Mary Seddon XPenny Impey XMary Seddon XJonathon Gray XPenny Impey X

HQSC Carmela Petagana X

Richard Sullivan (ADHB) X

Deirdre Maxwell XChris Lewis - Lead for Lung XMark Lane - Lead for Bowel XGarth Poole - Lead for Breast XRichard Doocey - Lead for Haemotology XRichard Sullivan (Chair) XAda Schuler (NDHB) XLes Garczynski (NDHB) XJo Brown (WDHB) XRobyn Dunningham (ADHB) XPeter Lowry (ADHB) XPauline Hanna (CMDHB) XLibby Nelson (CMDHB) XNick Chamberlain (NDHB)

XPeter Sandiford (WDHB) XRichard Sullivan (ADHB) XWilbur Farmilo X

First, Do No Harm

Region

ADHB

WDHB

CMDHB

Life and Years

CMDHB

ADHBIS

Network Tumour Streams

Cancer Control Steering Group Chairs

healthAlliance

FIRST, DO NO HARM

WDHB

NDHB

REGIONAL IS GOVERNANCE / LEADERSHIP GROUP

CANCER

Regional Oncology Operations Group


Tony Scott (WDHB) XHelen McKenzie XKyle Eggleton XAda Schuler XAndrew Potts XBrandon Wong X

Karen O’Keeffe XPeter Wood XLes Garczynski XNigel Harrison X

Stephen Jennison XBarbara O’Shaughnessy XDebbie Holdsworth XHamish Hart XPeter Lowry XJim Kriechbaum XJim Stewart XMark Webster XPam Freeman XPeter Ruygrok XBrad Healey XAndrew Kerr XPauline Hanna XLeanne Elder XPatrick Kay XWing Cheuk Chan X

Diabetes Jo Rankine X

Andrew Brant X

Region Siobhan Isles XRoger Tuck XClair Mills XVicki Scott XTimothy Jelleyman XTim Wood XMarianne Cameron XRichard Aickin XCarol Stott XAlison Leversha XPhillipa Anderson XSue Miller XRachel Scully XDavid Jensen XLouise McCarthy XNeil Hefford XKaren Hoare X

Alliance Health Plus Alan Moffit X

vacant X

Jo Rankine XNeil Beney XNicole McGrath XAndrea Taylor XRose Lightfoot XShane Cross XAndrew Brant XJean McQueen XRick Cutfield XStephanie Muncaster XMichele Garrett XKim Bannister XJim Kriechbaum XPaul Drury XBrandon Orr-Walker XHelen Liley XAndrew Kerr XHelen McKenzie X

CMDHB

NDHB

WDHB

NDHB

Region

CARDIOVASCULAR DISEASE

ADHB

Life and Years

ADHB

WDHB

Life and Years

Life and Years

CMDHB

CVD

DIABETESRegion

GAIHN

CHILD HEALTH

NDHB

WDHB

ADHB

CMDHB

NHC


Mike Roberts XAlan Davis XChris Pegg X

NDHB Alan Davis XGavin Pilkington XMartin Connolly XTim Wood XJanet Parker XRik Walstra XRichard Worrall XJane Lees XTrina Johnson XKate Milford XGeoff Green XShankar Sankaran XDana Ralph-Smith X

Christian Health Care Trust

Liz WebbX

Methodist Mission Northern

Andrea McLeod X

The Selwyn Foundation

Bart Nuysink X

Region Chris Pegg XNDHB Alan Davis XWDHB Dean Kilfoyle XADHB Alan Barber XCMDHB Geoff Green X

Gloria Johnson (CMDHB) XIain Nicholson XSue Wyeth XPatricia Palmer XMurray Patton XHelen Wood XJean-Marie Bush XHelen Wood XClive Bensemann XRobert Ford XTess Ahern XSonya Russell XPeter Watson X

Barry Snow (ADHB) XLeigh Manson (ADHB) XMargareth Broodkoorn XStephen Jennison X

WDHB Andrew Brant XADHB Margaret Dotchin XCMDHB Beven Telfer XNRA Sarah Prentice X

Region

NDHB

HEALTH OF OLDER PEOPLE

Life and Years

ADHB

CMDHB

Life and Years

Life and Years

STROKE

WDHB

ADVANCE CARE PLANNING

Region

NDHB

MENTAL HEALTH & ADDICTIONS

CMDHB

WDHB

The Informed Patient

Region

Life and Years

ADHB

NDHB David Hammer

Mehran Zareian

Ross Henderson

Margaret Wilsher

Ross Hewett

Steve Absalom

CMDHB Pauline McGrath

Ross Boswell

Arthur Morris

Paul Ockelford

Ross Anderson

Don Mikkelsen

Richard Lloydd

Steven Martin

Region Sarah Prentice

LABORATORIES - JOINT ADVISORY GROUP

DML

Services

LTA

ADHB

WDHB


Kate Aitken (WDHB) X

Gloria Johnson

Siobhan Isles XAlbert Eshun XAndrew Howes XAda Schuler XDavid Cranefield XLeith Hart XDavid Milne XSally Vogel XRaewyn Curin XGloria Johnson XSally Urry XPaul Hewitt X

Primary Care Barnett Bond X

Paul Baines XJillian Sutherland X XJohn Kristiansen X XTim Wood X

ADHB Katie Daniel XCMDHB Lynanne Stanaway X XRegion Jillian Sutherland X X

Andrew Potts X Rob Coup X Jo West XJohn Cullen XCath Cronin XLynne Butler XMark Watson XGreg Balla XNgarie Buchanan XJustin Kennedy-Good XVanessa Beavis XGillian Cossey XLiam Sheridan XWilbur Farmilo XRachel Rush XSarah Prentice X

Services

Region

NDHB

WDHB

ADHB

CMDHB

RADIOLOGY

Region

ADHB

WDHB

WDHB

NDHB

Services

PHARMACY

Services

ELECTIVES

NDHB

CMDHB


Northern Region Health Plan – May 2013 Appendix A.2 Page 1 of 36

Appendix A.2:

Our Priority Goals – Implementation Plan Matrices


First, Do No Harm Context

We are harming patients within the health system. A New Zealand study showed that 12.9% of New Zealanders admitted to hospital suffered an unintended adverse event caused in the management of their condition(s) rather than underlying disease, less than 15% of these adverse events were associated with permanent disability or death and 33% were significantly avoidable1. Avoidable serious adverse events translated to around 276,000 bed days. At an average cost of NZ$13,000 per adverse event, the cost of preventable adverse events is estimated to be around NZ$573 million per annum. Whilst these results are not atypical of any OECD country, no significant systematic change has been made to reduce these harmful events within the New Zealand health sector. The development of the Northern Region’s First, Do No Harm (FDNH) campaign is an acknowledgement that the time has come to have a focussed effort on improving the quality and safety of our health system and to raise the profile of patient safety. Harm minimisation not only improves the patient experience, by reducing suffering associated with unintended harmful effects of treatment, but also improves value for money, by reducing waste associated with provision of ineffective services and interventions to reduce harm. In April 2013, the Health Quality and Safety Commission (HQSC) will be launching a national patient safety campaign. The focus of this campaign includes areas that the Northern Region had identified as priorities. Going forward, FDNH will continue to be the focal point for assisting the Northern Region achieving the national and regional patient safety goals. As such, the FDNH implementation plan includes close alignment to the national priorities and ensures that the national quality and safety markers are an inextricable part of the plan. Objectives Linkages

The FDNH campaign is a vehicle to spread effective process changes that have been shown to reduce harm associated with the provision of healthcare. Main drivers in this priority area include: Having an engaging communication strategy Strong partnership with consumers and clinical staff

‘safer care together’ An effective measurement dashboard to track

progress Fostering regional learning ‘all teach, all learn’ Building the momentum of a safety culture

Health of Older People (HOP) Network

Health Quality and Safety Commission

District Health Boards (DHB) Age-related residential care

(ARRC) sector Primary care networks Consumer support networks

Key achievements Since the launch of the FDNH regional patient safety campaign activities in December 2011, the campaign has primarily focused on building the will, ideas and ability to execute the changes that will result in the reduction of harm. The strength of the campaign to date has been in bringing the region together to focus on particular patient safety topics and providing space and opportunity to learn and share how to achieve sustainable changes. Key achievements over the past 12 months include:

- The use of a formal improvement methodology to guide improvement activities. - Agreed measurement metrics for falls and pressure injuries. - Formal collaborative established on reducing falls and pressure injuries. - Engagement of ARRC sector in the falls and pressure injuries collaborative. - Provision of learning sessions and workshops. - One DHB showing a ‘shift’ in the reduction of harm from falls.

1 Davis P, Lay-Yee R, Briant R, Ali, W, Scott, A, Schug, S. Adverse events in New Zealand public hospitals I: occurrence and impact. Journal of the New Zealand Medical Association, 13 December 2002, Vol 115, No 1167.


- Supported clinical staff in use of data for improvement work. - Strong linkages continue with other work programmes (i.e. HQSC, HOP Network) to

ensure alignment with national and regional programmes. - Regional GTT workshop held and GTT implemented in all Northern Region DHBs. - Numerous activities/changes tried and tested across the Northern Region to improve

patient care and reduce harm. This activity, combined with the collaboration and sharing of learning, is helping to provide ‘safer care together’. Some examples are: Transfer of Clinical Information ‘yellow envelope’: this envelope has a checklist of

vital patient information printed on it and has helped minimise errors and delays during transfer of care from ARRC facilities to hospital and back.

Intentional rounding: a systematic approach to rounding can improve patients’ experiences of care and build their trust, and improve safety and reliability of care.

Raised the profile of regional patient safety culture – Created space for learning and sharing ideas. – Launched FDNH campaign website www.firstdonoharm.org.nz on 30 March with 4114

unique users to end January 2013. – Three-monthly e-newsletters distributed to 130 subscribers. – Regional ‘How to’ guides underway for falls and pressure injuries.

2013/14 Implementation Plan

Item First, Do No Harm - Process / Action 2013/14 Quarter

completed by 2014/15 2015/16

1. First, Do No Harm Measures

Reduction in falls causing major harm in the acute sector to a rate of less than 0.07 per 1000 patient days

Q1-Q4

ongoing √

20% reduction in falls causing major harm in those age-related residential care (ARRC) facilities that have implemented a programme.

Q3-Q4

ongoing √

75% of ARRC facilities will have implemented a falls reduction programme Q3-Q4

ongoing √ √

Reduction in pressure injuries Grades 3 and 4 (‘never events’) to zero in the acute sector

√ √

20% reduction in pressure injuries in those ARRC facilities that have implemented a programme

Q3-Q4

ongoing √

Monitor target of <1 CLAB per 1000 line days Q1-Q4

ongoing √

Reduction in healthcare associated infections measures to be developed in line with national/regional work

Q1-Q4

ongoing √ √

2. Foundation Activity

1 Appoint additional Programme Support/Administration Q2

2 Appoint additional Implementation Managers to work across falls, pressure injuries, healthcare associated infection, medication safety and transfers of care work streams

Q2

3. Process Activity

3a. Work streams

Reduce harm from falls

3 Engage additional acute and ARRC sector teams in regional Falls and Pressure Injuries Collaborative in partnership with Health of Older People

Q1-Q4

http://www.firstdonoharm.org.nz/�



completed by 2014/15 2015/16

(HOP) Network

4 Provide learning opportunities for DHBs and ARRC facilities Q1-Q4 √

5 Develop regionally consistent method to collect falls data for quality and safety markers

Q1-Q4 ongoing

6 Finalise and roll-out regional ‘How to’ guide for reducing harm from falls Q1

7 Incorporate falls data into regional dashboard of measures of harm Q1-Q4

ongoing √ √

8 Develop and implement exit strategy to incorporate reducing harm from falls initiatives into business as usual

√ √

9 Link with national patient safety campaign Q1-Q4

ongoing √

Reduce harm from pressure injuries

10 Engage additional acute and ARRC sector teams in regional Falls and Pressure Injuries Collaborative in partnership with Health of Older People (HOP) Network

Q1-Q4

11 Provide learning opportunities for DHBs and ARRC facilities Q1-Q4 √

12 Finalise and roll-out regional ‘How to’ guide for reducing harm from pressure injuries

Q1

13 Incorporate pressure injuries data into regional dashboard of measures of harm

Q1-Q4 ongoing

√ √

14 Develop and implement exit strategy to incorporate reducing pressure injuries initiatives into business as usual

√

Reduce harm from healthcare-associated infection (HAI)

15 Maintain and monitor monthly reporting of CLAB rates for Northern Region Q1-Q4

ongoing √ √

16 Select priority areas in consultation with region/national work for joint project using collaborative framework in a phased approach

Q1-Q4

ongoing √ √

17 Establish project aims, project charter and measurements Q1-Q4

ongoing √ √

18 Recruit collaborative teams Q1-Q4

ongoing √

19 Organise and hold learning sessions Q1-Q4

ongoing √ √

20 Identify and package evidence-based ideas and practices Q1-Q4

ongoing √ √

Improve patient safety during transitions

23 Evaluate regional implementation of Transfer of Clinical Information ‘yellow envelope’ in partnership with HOP

Q2

Improve medication safety

24 Undertake stock take of medication safety activities in the region Q2 – Q3

25 Identify and establish priorities in alignment with national work Q3-Q4

ongoing √ √

26 Facilitate transfer of knowledge across the region on improving medication safety

Q1-Q4

ongoing √ √

Reduce peri-operative harm

27 Conduct stock take on how surgical checklist is used and implemented in each DHB

Q3-Q4



completed by 2014/15 2015/16

28 Identify and establish priorities in alignment with national work √ √

Utilise Global Trigger Tool (GTT)

29 Share findings from GTT across the region to ensure GTT outcomes are used more effectively to identify patient safety issues and develop appropriate targeted programmes to address them

Q1-Q4

ongoing √

30 Link with national activities Q1-Q4

ongoing √

3b. Workforce

Develop a quality improvement culture

31 Provide network learning events to improve capacity and capability for improvement activities

Q1-Q4

ongoing √ √

32 Identify and recruit clinical leaders and managers in DHBs/ARRC to participate in patient safety activities

Q1-Q4

ongoing √ √

33 Establish consumer representation as part of patient safety campaign Q1-Q4

ongoing √ √


Cancer Services Context Cancer was the leading cause of death for both males and females in New Zealand in 2009, accounting for 28.9% of all deaths. The impact on people diagnosed with cancer and their whanau can be devastating for months and sometimes years. A whole of system approach via tumour streams is improving access to services and waiting times for patients, with strong multidisciplinary expertise and standard care pathways. Notwithstanding the success of our approaches to date, cancer remains a significant concern for our population and health services.

Objectives Linkages

To continue to meet national and local health targets and related measures

To progress Faster Cancer Treatment indicator measurements and service improvements

To progress tumour stream-related improvements including standards implementation, models of care work and others

Information systems strategic management and support

Workforce development

Diagnostic services

Key achievements since July 2012 Last year the sector achieved all the following outcomes as planned:

√ 100% of patients requiring radiation therapy will receive this within four weeks. √ 100% of patients requiring chemotherapy will receive this within four weeks. √ Lung cancer regional targets

55% of patients referred urgently with high suspicion of lung cancer to first cancer treatment within 62 days.

78% of patients referred urgently with high suspicion of lung cancer to first specialist appointment (all treatment types) within 14 days.

74% of patients with lung cancer as confirmed diagnosis who receive first cancer treatment within 31 days of decision to treat (all treatment types).

√ Commence four year trial of a bowel screening programme at Waitemata DHB. √ Northern Region prioritisation criteria for colonoscopy implemented and baselines

determined, with progress toward Ministry of Health delivery timeframes. √ National Medical Oncology Prioritisation Criteria implemented for assessment and

chemotherapy wait times. √ Development of four of national tumour stream standards managed through the

Northern region. √ Development, approval and commencement of Northern Region Faster Cancer

Treatment Implementation Plan. √ Implementation of new Care Coordinator positions within DHBs.



Item Cancer Services: Process/Action 2013/14 Quarter

completed by 2014/15 2015/16

1. Patient Outcome Measures

100% of patients requiring radiation therapy will receive this within four weeks (National health target)

Ongoing

100% of patients requiring medical oncology treatment will receive this within four weeks (National health target)

Ongoing

62 day indicator – proportion of patients referred urgently with a high suspicion of cancer who receive their first cancer treatment (or other management) within 62 days from date of referral

Q1 ongoing

14 day indicator – proportion of patients referred urgently with a high suspicion of cancer who have their first specialist assessment within 14 days

Q1 ongoing

31 day indicator – proportion of patients referred urgently with a high suspicion of cancer who receive their first cancer treatment (or other management) within 31 days of decision to treat

Q1 ongoing

50% of patients accepted for an urgent diagnostic colonoscopy receive their procedure within 2 weeks (14 days)

Q1 ongoing

50% of patients accepted for a diagnostic colonoscopy receive their procedure within 6 weeks (42 days)

Q1 ongoing

50% of people waiting for a surveillance colonoscopy receive their procedure within twelve weeks (84 days) of the planned date

Q1 ongoing

2. Foundation Activity – Completed

3. Process activity

3a. Models of care and service

Regional Health Targets

1 Regional service to work collaboratively through ROOG process to achieve health targets

Q1 ongoing

2 All DHBs to progress and resolve capacity and resourcing issues around achievement of colonoscopy indicators

Q1 ongoing

Faster Cancer Treatment

3

Continue to develop measurement capacity and improvements in cancer pathways for all cancers, across all DHBs by tumour stream, consistent with Regional Implementation Plan priorities. Note improvements possible through progressive prioritised implementation of Regional Medical Oncology Models of Care Plan and National Radiation Oncology Plan when developed.

Q1 ongoing

4 Engage with DHBs through the tumour stream approach to agree service improvements in lung, bowel and colonoscopy access and timeliness to treatment, reflecting progress against targets.

Q1 ongoing

5

Continue national tumour stream(s) standards of service provision by working regionally to prioritise phased implementation across nominated tumour streams, to include an audit of one tumour standard, and an annual audit of lung cancer standards using tumour stream process.

Q4

6 Scope regional Cancer clinical data repository requirements consistent with the Northern Region IS Strategy

Q4

7 Continue the four year trial of a bowel screening programme implemented at Waitemata DHB (Year 1 underway)

Ongoing

Delivering Whole of System Care


Item Cancer Services: Process/Action 2013/14 Quarter

completed by 2014/15 2015/16

8

Work with the Ministry of Health to agree, and in time implement the priority areas identified in the National Medical Oncology Models of Care Implementation Plan 2012/13, within available resources. To include increased standardisation of processes, procedures and workforce across the region.

Q1 ongoing

9

Improve the functionality and coverage of MDMs across the region to include the development of electronic MDM templates for up to 5 tumour streams and work regionally to improve the effectiveness of MDMs. In addition, report % of patients presented to MDM by tumour streams with electronic templates (commencing December 2013)

Q4

10 Implement the priorities identified in the Prostate Cancer Quality Improvement Plan through the establishment of a Regional Prostate Cancer Steering Group to identify and oversee implementation of regional priorities.

Q2 ongoing

11

Provide regional support for the implementation of the extended Auckland District Health Board Bone Marrow Transplant service opening by the end of 2013. Work with the Ministry of Health and other BMT providers to achieve nationally consistent BMT waiting times.

Q2 ongoing

12 Provide regional support for the ongoing activities of the Waitemata DHB Bowel Screening Pilot

Ongoing

13 Continue to work with the Ministry of Health to support the implementation of the Endoscopy Quality Improvement Programme

Q1 ongoing

14 Present an annual equity assessment, with a focus on Maori, to include FCT indicators for lung cancer, % presentation at MDM for lung cancer by ethnicity, and colonoscopy indicators

Q4

15 Develop a Regional Strategic Plan for Cancer, to include a Maori Cancer Control Strategy, to inform the 2014/5 Regional Health Plan.

Q4

3b. Workforce

16 Increase the provision of oncology service through the establishment and implementation of Tele-health services.

Q3

17 Support the commitment of the region and DHBs to train and provide professional development to cancer nurse coordinators, including attendance at national and regional training and mentoring forums.

Q4 ongoing

18 Through engagement with Care Coordination staff across the region, develop and pilot a supportive care screening tool.

Q4

3c. Information Systems

19 Progress scoping requirements for Regional Non-Surgical Cancer Patient Management System as a precursor to a regional clinical data repository.

Q2


Cardiovascular Disease Context Improving access to cardiac services will help our population to live longer, healthier, and more independent lives. The Northern Region’s Cardiac Clinical Network has identified the following issues with CVD management in the Northern Region;

There is variation in both access and timeliness of access to core cardiology assessment, investigation and management across the primary-secondary continuum.

Deprived and geographically and/or culturally isolated population groups do not meet accepted intervention rates and health outcomes.

o The reporting infrastructure to measure activity and support improvement initiatives is incomplete across the region for both primary and secondary care.

Objectives Linkages

We want to achieve:

Adequate, timely and equitable levels of access to key cardiac assessment and management across the patient journey through primary and secondary care;

Regionally consistent monitoring and auditing of investigations, management and outcomes across the four DHBs including primary care.

Models of care that better meet the demand and and deliver regionally agreed standards of care by;

o Reducing waiting times for First Specialist Appointments and follow up visits.

o Providing better support for discharged patients.

o Reducing patient admissions.

o Improving patient outcomes

Diabetes Network

DHBs

National Cardiac Network

DHB Shared Services

GAIHN

PHOs

Key achievements since July 2012

Last year the Northern Region’s Cardiac Clinical Network met the following objectives for the 2012/13 Regional Service Plan.

√ Strengthened the Northern region’s Cardiac Clinical Network by;

– Appointing a Clinical Leader, for a two year term, to succeed the current Clinical Leader.

– Integrating primary care in work stream initiatives. – Establishing a closer working relationship with the Diabetes Clinical Network

and sharing initiatives that combine CVD risk Management and Quality Improvement with diabetes clinical indicators

Regional KPIs; √ Reporting initiated and underway:

– Cardiac Surgery – Primary Care Adherence – Cardiology First Specialist Appointment Waiting times including chest pain

FSAs and follow ups – Inpatient Coronary Angiography for ACS – Outpatient Angiography – Door to Balloon for Primary PCI


– Trans-thoracic Echocardiography – Summary report for all KPIs – National Medicine Adherence Report – Electrophysiology Service Report – PHO Medicine Adherence report – Medicine Adherence- Comparison for PHOs report

√ Developed: – After hours Primary PCI- Established standardised transfer processes across

the Northern Region along with ‘ECG transmission by ambulance process’, This has been successfully implemented at CMDHB and is in the process of being rolled out at WDHB.

– Ongoing maintenance of Cardiac Surgery Targets have been achieved and to ensure the appropriate capacity is available to meet targets priority has been placed on operating CVICU (ACH) at higher capacity with the appointment of and additional cardiac surgeon and contracting to outsource cardiac procedures work programmes

– Documentation further developed to support CVD Risk Management and discussed within both the secondary and primary care sector underpinning the in-hospital opportunistic CVD risk screening initiative along with increased screening in the primary sector.

– Clinical Guidelines for treating out or hours STEMI are completed and have been circulated for use within each DHB

– An agreed Regional Electrophysiology Services (EP) model of care has been developed and regional reporting for EP services is now underway

– Sector feedback sought and received re the Northern Region ‘Primary Care Medication’ Adherence in CVD report

– A Medicine Adherence report has been developed for PHOs to support practice based Quality Improvement

– A report for Medicine Adherence by comparison for PHOs has been developed.

– Agreement has been gained from both the MOH and most of the PHOs within the Northern Region to provide data in support the development of the CVD Risk Assessment registry.


Item Cardiovascular : Process/Action 2013/14 Quarter

completed by 2014/15 2015/16


80% of all outpatients triaged to chest pain clinics to be seen within 6 weeks for cardiology assessment and stress test.

Q4 √ √

90% of out-patient coronary angiogram waiting time to <3 months. Q2 √ √

70% of patients presenting with an acute coronary syndrome who are referred for angiography receive it within 3 days of admission ( day of admission being day 0 )

Q2 √ √

95% of patients presenting with Acute Coronary Syndrome who undergo coronary angiography have completion of ANZACS QI ACS and Cath/PCI registry data collection.

Q2 ADHB/ WDHB/CMDB

Q4 NDHB

80% of patients presenting with ST elevation MI and referred for PCI will be treated within 120 minutes. (There may be some variation for patients from NDHB due to geographical isolation and dependence on emergency helicopter transport.)

Q4 √ √

Maintain the nationally agreed cardiac surgical delivery and waiting list management targets.

Q1 √ √



completed by 2014/15 2015/16

90% of eligible patients will have had their CVD risk assessed in the last 5 years

Q4 √ √

Aim for 95 % of outpatient Echos to have been completed within 5 months of referral

Q4 Reducing to 4

months

Reducing to 3

months

2. Foundation Activity - complete

3. Process activity


1 Develop a regional plan for Electrophysiology Services to better meet the patient demand.

Q4 √

2 Develop a process to maintain ACS guidelines as a living document to allow for continuous improvement

Q3 √ √

3 KPIs to be further developed to include intervention rates by DHB for all services

Q3

4 Continuing to develop the regional Primary PCI service in collaboration with St John’s ambulance and ED staff to support more rapid transit of ST elevation MI patients direct to a PCI Centre.

Q4

5 Current measures will be continued and closely monitored to ensure the appropriate capacity is available to meet cardiac surgery across the region.

ongoing

6 Utilise urgency scores to determine priority for treatment within agreed timeframes

ongoing

7 Support the recommendations from the CVD Risk Management working group to improve CVD assessment and management rates across the sector. This is in support of the CVD Risk assessment measure.

Ongoing √ √

8 Support in-hospital opportunistic CVD risk screening.

Pilot this in CMDHB and WDHB. To be evaluated and considered for implementation in remaining 2 DHBS.

Q2

WDHB & CMDHB

Evaluation of pilot

Consider implementation in NDHB & ADHB

9 Establish quality improvement groups in each DHB Cardiology department to support regional initiatives/ KPI targets

Q4

10 Improve access to Echo to support diagnosis of Heart Failure and other conditions including those requiring cardiac surgery.

Q3 √

11 Actively support existing Smoking Cessation Programmes ongoing √ √

3b. Workforce

12 Host an Allied Health/Cardiac Nurse Specialist annual regional forum to share existing models of care across primary and secondary levels

Q3

Agree consistent access pathways and triage processes Q4

Engage with key stakeholders in each DHB to identify barriers to implementation

Q4

Gap analysis of suggested changes for each DHB to implement new pathway

Q4



completed by 2014/15 2015/16

Implement the preferred pathway and tools √


13

Implement Acute Predict (ANZACS QI) in NDHB and complete the implementation of this at ADHB whilst continuing to provide ongoing support for use of KPI reporting and ACS quality improvement throughout the region

Q2

14 Support the population of the CVD Risk Registry Q4

15 Support integration with Éclair/ Concerto for ECG transmission by ambulance

Q1

3d. Capital and other expenditure

16 Additional FTE may be required to support ECHO and EP √ √

17 Ongoing FTE commitment for additional FTE for in-hospital CVD risk assessment in support of target

√ √

18 CMDHB business case for 2nd Cardiac Catheter lab

19 Cost implications for maintenance of equipment and call charges for ECG transmission by ambulance

√ √


Child & Youth Health Child Health

Context

Most children born or living in the region enjoy good health, but some do not, with the distribution of poor health marked by significant socio-economic and ethnic differences. Inequities can be clearly seen across a range of measures. Maori children and Pacific children experience poorer health than non-Maori, non-Pacific children. Children living in poorer neighbourhoods also have poorer health.

The determinants of child health outcomes extend beyond the traditional boundaries of the heath sector. The health outcomes of our children are affected in a very real way by issues such as the quality of housing, maternal mental health, parental smoking, nutrition income, employment status of caregivers, and urban design which challenge us to think more broadly about solutions. Problems such as overcrowded and unhealthy housing contribute to unacceptable rates of diseases such as skin sepsis and rheumatic fever.

Objectives Linkages

Six main objectives are to:

Optimise health outcomes, including reducing inequities in health outcomes

Use a regional voice to advocate improvements in the upstream determinants of child health

Target our interventions at those who need them most

Improve the capability and capacity of our workforce so that a child receives quality care regardless of where they present

To pool health and other social agency resources more effectively

To achieve greater consistency and quality of care for children

Direct engagement with child and maternity health providers

Vulnerable Children Action Plan and work to progress Better Public Services particularly for RF and Immunisation

GAIHN work plan

NRHP Respiratory priority

Auckland and Northland Councils

Other social sector agencies such as Housing and Education

MoH / NHB work on eradicating Rheumatic Fever

Regional groups for maternity, youth, primary care, etc

ARPHS

Children’s Commission

Note: Children are defined as 0 – 14 years, and youth as 15 – 24 years, for the purposes of this document

Inter-linkages between the NRHP and GAIHN work The region has two key programmes of work which include a focus on child health: the Northern Region Health Plan and the Greater Auckland Integrated Health Network. Both of these have a broader focus of which child health is one part. The Child Health Network has worked hard to ensure good alignment and a complementary approach between these two programmes. This approach is summarised as:

The GAIHN child health workstream is directed by the network and aligned with the priorities and focus of the NRHP

The role of the child health GAIHN workstream is to operationalise aspects of the NRHP child health implementation plan, particularly around the development and implementation of paediatric clinical practice guidelines and supporting initiatives to enrol, engage and provide interventions for vulnerable children and pregnant women

There is good cross membership on the network and GAIHN


It is also noted that other initiatives in the broader GAIHN workplan may impact child health, such as the development of the risk assessment tool. Development work on these initiatives will engage with the Child Health Network as appropriate to ensure their applicability for children. Key achievements since July 2012 The formal Northern Region Child Health Network was established in July 2012, building on a collaborative network in the metro area and various joint initiatives across the region. To date, the network has achieved: – Over 12,000 children have received better access to primary care through the school

based program to identify and treat Group A Streptococcus (to prevent Rheumatic fever) and skin infections

– Development of consistent guidelines to manage children who present in primary care for skin infections and lower respiratory tract infections.

– The groundwork for improving communication and training to prevent SUDI through a stocktake of SUDI policies and training in health providers across the region, and a hui for health professionals to develop a regional strategy


Item Child Health : Process/Action 2013/14

Quarter completed by

2014/15 2015/16


Hospitalisation rate per 100,000 region population for acute rheumatic fever is 10% lower than the average over the past 3-years

Q4

Improve primary care access to over 20,000 school-aged children (year 1-9) through the implementation of a school based health service focused on the identification and treatment of group A Streptococcal throat infections, and skin infections

Q3

Reduction in SUDI for: a) All babies b) Māori and Pacific babies

Trend tracked – 2 year delay

on data

Regional SUDI Action Plan implemented Q3

10% reduction in hospitalisation rate of serious skin infections for children aged 5- 14

Q4

Clinical guidelines and algorithms for skin infections implemented in 50% practices

Q4

50% increase in uptake of special immunisations for influenza and pneumococcus

Q4

Clinical guidelines and algorithms for skin infections implemented in 50% practices

Q4

90% of 8-month old children fully immunised Q1-Q4

ongoing

90% of enrolled patients who smoke and are seen in General Practice will be provided with advice and help to quit

Q1-Q4 ongoing

Progress to 90% of pregnant women who identify as smokers at the time of confirmation of pregnancy in general practice or booking with Lead Maternity Carer are offered advice and support to quit

Q1-Q4 ongoing

100% of 6-week old babies are enrolled with a GP Q1-Q4

ongoing


1 Review network terms of reference Q4

2 Further develop KPI framework Q3




2014/15 2015/16

3. Process activity


Communications and engagement

3 Review and adapt child health communications plan, prioritising public health messages for SUDI and Rheumatic Fever and align with DHB communication plans

Q2

4 Implement communications strategy Q1-Q4

ongoing √ √

5 Explore options to enable better sharing of individual child and family information with appropriate professionals, whether electronically or other means

Q3 √

Upstream determinants – health agencies

6

Develop effective integrated models of care to improve health and other social outcomes from pre-pregnancy to childhood:

Develop and agree a population health framework Identify the areas where there are good, and poor,

approaches, and the priorities to meet the gaps Work with localities, IFHC’s and other mechanisms to:

o Strengthen transfers of care between providers o Strengthen links between pregnant women and

primary health care services Define “high-risk” pregnant women, children and

families/whanau

Support smoking cessation initiatives, including a pregnancy pathway for Maori women who smoke

Facilitate linkages to improve early childhood education

Q1-Q4 ongoing

√ √

7 Support initiatives to check vaccination status for every child <5 yrs who presents to a health provider

Q1-Q4 ongoing

√ √

8 Support initiatives to reduce smoking exposure in children Q1-Q4

ongoing √ √

9 Participate in the pilot of the Children’s Team concept in Northland DHB

Q3

Upstream determinants – cross sector

10

Prioritise advocacy and coordination of activities with Housing and other agencies to identify and implement initiatives to reduce RF, LRTI and other childhood illnesses, including the quantity and quality of housing stock

Q1-Q4 ongoing

√ √

11 Work with key stakeholders to progress the Better Public Service priorities for Rheumatic Fever and Immunisation, and the initiatives led by other agencies

Q1-Q4 ongoing

√ √

12

Continue to advocate for and support prioritised and funded initiatives in alignment with other agencies to

Improve the quality and safety of housing stock

Strengthen partnerships with schools on health initiatives

Support injury prevention initiatives

Improve school travel plans, cycle ways, swimming pools (Council)

Ensure availability of subsidised car seats

Q1-Q4 ongoing

√ √

13

Support the development and implementation of an assessment framework to identify vulnerable families and children, building on existing national and whanau ora work, and encompassing:

Whanau ora

Family friendly front page for primary care

Q2




2014/15 2015/16

Tools, resources and training

National work e.g. Children’s Action Plan

A collaborative approach with other social agencies

14 Develop a consistent and accurate process to inform other agencies once a child has died

Q2

Skin infections, cellulitis and abscesses

15 Support the primary and secondary care implementation of clinical pathways for the spectrum of skin infections, cellulitis and abscesses

Q1-Q4 ongoing

√ √

16 Implement guidelines for the management of skin infections cellulitis and abscesses as part of the healthcare provided in school based health services

Q1-Q4 ongoing

√ √

17 Measure effectiveness of implementation through measures such as clinical audit tools, secondary care utilisation and practitioner and patient experience of pathways.

Q3

18 Explore more appropriate and accessible options for providing surgical intervention to avoid or reduce hospitalisation

Q4 √ √

Rheumatic Fever

19 Support the regional champions for RF to lead regional work to reduce RF

Q2

20 Each DHB to develop implementation plans, aligned to the national guidance

Q1

21 Continue to implement school based program to identify and treat GAS Q1-Q4

ongoing √ √

22 Continue to strengthen commitment for RF among health agencies to achieve the reduction in rate

Q1-Q4 ongoing

√ √

23 Review the current pathway for acute RF cases in secondary care to identify issues and alignment to national standards

Q2

24

Support initiatives to improve collaboration across community and hospital services to ensure consistent follow-up of acute RF cases to achieve full secondary prevention antibiotic prophylaxis and appropriate referral to services

Q1-Q4 ongoing

√ √

25 Develop a specific communications campaign for health professionals to identify and treat GAS and RF

Q2

26 Support the implementation of Sore Throat and diagnosis of RF guidelines in primary care

Q1-Q4 ongoing

√ √

SUDI

27 Implement the regional safe sleep policy across DHB and DHB funded health facilities

Q1-Q4 ongoing

√ √

28 Support SUDI training programs for health professionals on induction and as part of professional development in DHBs and with other providers

Q1-Q4 ongoing

√ √

29 Develop and implement a consistent strategy to support families in particular Maori and Pacific who have had a SUDI death to manage subsequent offspring

Q1-Q4 ongoing

√ √

30 Repeat stock-take of SUDI policies and training across the sector to assess for changes

Q4

Unintentional Injuries




2014/15 2015/16

31 Participate in the development of injury prevention priorities in collaboration with Safekids

Q1-Q4 ongoing

√ √

32 Implement age and developmentally appropriate injury prevention communications and support to children and their families

Q1-Q4 ongoing

√ √

33

Support initiatives to improve access and usage of safe child restraint equipment:

Ensure existing DHB transport policies and practice reflect safe transportation for children in DHB vehicles and for children leaving in private vehicles

Include car seat and safety information to families on discharge from hospital and primary care

Q1-Q4 ongoing

√ √

34 Agree and commit to provide and review evidence bases to support child injury prevention action

Q3

35 Expand paediatric trauma working group to formalise trauma guidelines and bypass protocols

Q3 √ √

Lower Respiratory Tract Infections

36 Implement clinical pathways for the assessment, diagnosis, treatment and follow up of LRTI in primary care

Q1-Q4 ongoing

√ √

37 Improve uptake of special immunisations by developing a process by which all eligible children are identified within the health care continuum and linked with their primary care provider to receive them

Q2

38 Develop a clinical pathway for chronic cough Q2

39 Measure effectiveness of implementation through measures such as clinical audit tools, secondary care utilisation and practitioner and patient experience of pathways.

Q3

3b. Workforce

40 Develop workforce requirements in line with the national work on Children’s Workforce Action Plan

Q2

41 Work with clinical training agencies to improve the knowledge and competency in child health topics in professional development programmes eg. CME and CNE programmes

Q1-Q4 ongoing

√ √

42 Support implementation of consistent child health standing orders for registered nurses

Q1-Q4 ongoing

√ √

43 Support implementation of new nurse-led models in primary and community health care

Q1-Q4 ongoing

√ √

44 Improve the availability of Social Workers and Community Health Workers in the community to work with vulnerable families and whanau across sectors

Q1-Q4 ongoing

√ √

3c. Information Technology and Systems

45 Provide ongoing support to the Auckland Regional RF register, the IT and resource requirements for long term sustainability

Q1-Q4 ongoing

√ √

46 Explore how data from PMS in primary and secondary care can be used to identify target group for enhanced immunisation schedule

Q2


Youth Health

Context

New Zealand has a poor record when it comes to young people’s health and wellbeing. Rates of youth suicide, death from motor vehicle injuries, unintended pregnancy and drug and alcohol use are among the highest in the Western world. While most young people born or living in the region enjoy good health, some do not, with the distribution of poor health marked by significant socio-economic and ethnic differences. Inequities can be clearly seen across a range of measures. Maori young people and Pacific young people experience poorer health than non-Maori, non-Pacific young people. Young people living in poorer neighbourhoods also have poorer health.

The determinants of youth health outcomes extend beyond the traditional boundaries of the heath sector. The health outcomes of our youth are affected by wider contexts comprising families, schools and communities, where issues such as poverty, disengagement from school and availability of alcohol are examples of risks which impact of the health and wellbeing of young people. The future of Auckland as a vibrant and economically healthy city depends on our young people being prepared to contribute to their families and communities in a rapidly changing and technology sophisticated world. This requires young people to be healthy, emotionally resilient and engaged in education and training with access to high quality health and social services.

Objectives Linkages

Six main objectives are to:

Optimise health outcomes, including reducing inequities in health outcomes

Use a regional voice to advocate improvements in the upstream determinants of youth health

Target our interventions at those who need them most

Improve the capability and capacity of our workforce so that a young person receives quality care regardless of where they present,

Pool health and other social agency resources more effectively

Achieve greater consistency and quality of care for young people

Northern Region Mental Health and Addictions network, and its focus on youth forensics

Youth health action plan

Youth development strategy

Auckland Council and its intersectoral groups

Northland Council and its intersectoral groups

Regional groups for maternity, youth, primary care, etc

Note: Youth are defined as 12 – 24 years, for the purposes of this document


2013-14 Implementation Plan

Item Youth Health : Process/Action 2013/14 Quarter

completed by 2014/15 2015/16


Develop clinical outcome measures

Rates of completed suicide

Rates of foregone health care Q1

ongoing

Rates of teenage pregnancy and terminations Q1

ongoing

Reduction in health risking behaviours Q1

ongoing

Reduction in the number of young people not in education, employment or training


1 Review network terms of reference Q4

2 Develop clinical outcome measures Q3

3 Review youth health standards of care Q4

3. Process activity


Youth appropriate primary care

4

Youth friendly accessible primary care across all areas

Review models of care appropriate for different communities

Review barriers to access to care for local population and solutions to address these eg provision of low/cost/ free care, hours of availability, bookings, clustering of services

Review Youth health standards of care document that is in draft form to finalise

Q2

5

School based services

Model of care/ best practice

Standing orders

GP/NP support

Integration with mainstream primary care

Integration with mental health

Services to all schools

IT systems

Q1-Q4 ongoing

√ √

6 Development of youth primary mental health care services and integration with specialist secondary services guided by best practice

Q3 √

Youth appropriate secondary care

7

Delivery of developmentally appropriate care to young people aged 12-24 in secondary/tertiary care in line with standards of care including

Planned transition between paediatric/ adult/ primary care services

Q2 √ √


Item Youth Health : Process/Action 2013/14 Quarter

completed by 2014/15 2015/16

Accessible youth friendly care

Inpatient environments that consider the developmental needs of young people

Youth appropriate resources in outpatients and inpatient settings

Peer support available

Linkages to external agencies to support youth development eg education providers, social services for young people, vocational support

3b. Workforce

8 Work with clinical training agencies to improve the knowledge and competency in youth health topics in professional development programmes eg. CME and CNE programmes

Q1-Q4 ongoing

√ √

9 Support implementation of consistent youth health standing orders for registered nurses

Q1-Q4 ongoing

√ √

10 Support implementation of youth friendly models in primary and community health care

Q1-Q4 ongoing

√ √

11

Work towards accreditation of practices/ professionals for working with young people:

Standards of care for practices

Workforce training for professionals

12 Support development of local champions/ leadership across the region in youth health.

Q1-Q4 ongoing

√ √

3c. Information Technology and Systems

13 Resolve issue of IT support for school based services to enable access to IT systems

Q1-Q4 ongoing


Diabetes

Context

Diabetes is a chronic disease that leads to disability through blindness, amputation of limbs, cardiovascular disease and renal failure - and it shortens lifespan. Nearly 82,000 people have diabetes in the region and this is projected to grow to 150,000 by 2026 (an increase of 82%). Certain ethnic groups experience higher rates of the disease, particularly Māori, South Asian and Pacific.

Objectives Linkages

There are two key drivers to this priority area

Cost – secondary services will not grow at the same rate that the diabetes population is expected to grow. This is further impacted by the global recession.

There are unacceptable health and life expectancy disparities between ethnic groups in particular Maori, Pacific and South Asian.

Northern Region Cardiac Network

Internal Stakeholders – Planning and Funding

External Stakeholders - Diabetes NZ, PHO’s, Ministry of Health

Key achievements since July 2011 The Northern Diabetes Network is committed to providing regional clinical leadership on diabetes prevention and management across the health system with the aim of achieving system wide integration and improvement for the improved health of at risk populations.

√ Implemented

– Developed Indicator set and report format – Undertook stock take of diabetes activity across the region – Developed an algorithm to support the implementation of the NZ Guideline on

Diabetes Management in Primary Care. – Developed a “Key Tips Sheet” for GPs on Diabetes Management – Developed an algorithm for Diabetes Initiation in Primary Care – Conducted regional consultation on the replacement on Diabetes Get

Checked programme – Obtained approval for the use of Test Safe diabetes data for quality

improvement – Developed the Quality Improvement Teams model in primary care as the

preferred care model with uptake from 3 DHB’s to pilot – Undertook a regional revision of the Diabetes Self Management Education

(DSME) to refine and standardise content, standards and evaluation – The region implemented the findings of the Diabetes Nurse Prescribing pilot

√ Started delivery of

– Indicator reporting – Embedding of NZ Guideline on Diabetes Management in Primary Care – Implementation of Quality Improvement Pilot(s)



Item Diabetes : Process/Action 2013/14


2014/15 2015/16


a 90% of eligible patients will have had a cardiovascular risk assessment in the last 5 years.

Q1 – Q4 √ √

b 70% of patients have good or acceptable glycaemic control Q1 – Q4 √ √

c 70% of Maori patients have good or acceptable glycaemic control Q1 – Q4 √ √

d 75% of diabetes patients have appropriate management of microalbuminuria (rising to 80% in 2014/15)

Q1 – Q4 √ √

e 75% of Maori patients with diabetes have appropriate management of microalbuminuria in MAORI patients with diabetes (rising to 80% in 2014/15)

Q1 – Q4 √ √

f 85% statin use in people with diabetes and CVD risk greater than or equal to 15% over 5-years (including those with a previous CV event)

Q1 – Q4 √ √

g 85% statin use in Maori people with diabetes and CVD risk greater than or equal to 15% over 5-years (including those with a previous CV event)

Q1 – Q4 √ √

h

Improve or, where high, maintain use of antihypertensive medication in patients with diabetes and a CVD risk greater than or equal to 15 percent over 5 years including those with a previous CV event. (75% rising to 80% in 2014/2015)

Q1 – Q4 √ √

i 38,000 patients undergo retinal screening Q1 – Q4 √

2. Foundation activity

Foundation in place. No additional activities planned.

3. Process activity


Indicator development and reporting (ethnicity, gender and age specific)

1 Continue reporting on current indicator set and align with National indicators Q1 – Q4 √ √

2

Develop further primary care indicators which are aligned to the NRDN Care Pathway eg:

o Waiting time for high risk / acute foot ulcer assessment and treatment

o Others as appropriate

Q4 √ √

3 Identify and develop pre-diabetes indicators targeting detection and management (aligned to NRDN Care Pathway once developed)

√

4 Identify and develop indicators/outcome measures for Diabetes Self Management Education (DSME)

√ √

5

Identify and develop in-patient indicators eg:

o Length of stay o Hypo admissions o Waiting time for referral to diabetes clinic (urgent, semi urgent,

not urgent) o Others as appropriate

√ √

Implement innovative models of care

6

Annual environmental scan of care models for their ability to improve care:

o Pre-diabetes patients

o Type 1 diabetes patients

o Type 2 diabetes patients

√ √




2014/15 2015/16

o Vulnerable / high risk populations eg Maori and

o Pacific and Asian (reducing inequalities) and

o Improving patient engagement and empowerment

7 Undertake a retinal screening study to inform best practice, screening volumes and indicator development

Q4 √ √

8 Monitor and support the implementation of the 3 Quality Improvement Teams (QIT) pilots

o Undertake an evaluation of QIT pilots and implement learnings

Q1 – Q4

√

9

Support the development of Nurse Led Clinics in primary care

o Convene working group to scope current issues and opportunities

o Host an annual workshop for the sector

Q4 √ √

Pre - diabetes

10 Develop a strategy / business case for pre-diabetes services √

11

Develop a pre-diabetes care pathway

o Convene working party

o Implement pathway

√ √

12 Identify self management/education needs of pre-diabetes patients √

Type 1 Diabetes

13 Scope feasibility and resources/education needed to support more Type 1 diabetes patients being managed in primary care settings

√

Promote the development and use of guidelines and pathways

14

Support the development and implementation of the Gestational Diabetes Guideline being developed by the Ministry of Health

o Provide advice and other input

o Adopt indicators when developed

√ √

15 Support the use of NRDN care pathway and NZ Guidelines in primary care via education and communication activities

Q1 – Q4 √ √

16 Conduct an annual review of the NRDN pathway and associated documents to ensure their relevancy and currency

√ √

Podiatry access and uptake

17

Develop a process for improving the identification and management of the High Risk foot eg educational needs, tools

o Convene working group (Q2)

o Stocktake/identify educational needs and tools and resources (year 1)

o Develop plan and metrics (year 2)

Q1 - Q4 √ √

18 Scope service user needs for community podiatry and develop business case as appropriate

√ √

19 Undertake podiatry DNA project and develop plan as appropriate √ √

Diabetes Care Improvement Package alignment

20

Develop a regionally aligned approach to the development and implementation of the Diabetes Care Improvement Package (DCIP) eg:

o Aligning where possible approaches to PHO contracting and target setting

o Aligning where possible approaches to service provision across the region

Q1 – Q4 √ √

In-patient care




2014/15 2015/16

21

Improve in-patient care of patients with diabetes:

o Convene working group to identify issues and opportunities to improve care

o Identify a process by which the diabetic patient is flagged on admission to hospital

o Align with Ministry work stream on medication safety eg insulin administration, prescribing

o Develop remedial plans as appropriate

Q4

√ √

DSME

22

Implement the revised DSME process

o Release revised standards and workbook and promote their use

o Progress alignment of regional evaluation tools and processes

Q1 - Q4 √ √

23 Develop a Regional DSME Governance Group to oversee and guide DSME quality and delivery

Q2

3b. Workforce

24

Grow the diabetes workforce and skill base

o Work with localities / local networks and QIT’s to support the development of an appropriately skilled workforce.

o Undertake a stocktake and prioritisation of diabetes educational courses and resources available

Q4 √

25

Develop a process to increase the capability of primary care to initiate insulin eg: via education sessions, clinics and mentoring

o Convene working party

o Obtain baseline data on practices who currently do this and the staff involved

o Identify resources and support needed

√

√

26

Develop and report regional HR metrics eg

o Diabetes workforce demographics

o Educational levels

o Training eg in cultural competency, insulin initiation

√ √


Indicator Reporting

27 Continue to enhance indicator reporting and access to TestSafe and primary care data

Q1 – Q4 √ √

28

Obtain regional DHB and primary care agreement to extend indicator reporting to primary care level

o Agree report format

o Agree feedback loop / circulation list

Q3

29 Develop a Pre Diabetes Register √


Health of Older People

Context

While the proportion of people aged 65+ living in the region is still relatively low, the rate of projected growth is very high over the next 20 years. This is significant because this age group is strongly associated with high admission rates, longer lengths of stay, high residential and community costs, prevalence of dementia doubling, and likelihood of more severe injuries/accidents.

Objectives Linkages

The key drivers for HOP are to:

Plan for projected growth in the population of older people including management of acute demand

Provide informed choice for older people in their care, minimise dependence

Protect the vulnerable and frail aged population who often have complex needs and are socially isolated in the community

Improve service coordination and deliver whole of system care through enhancing cooperation with primary, community and ARRC sectors underpinned by a knowledgeable workforce.

District Health Boards (DHB)

Age-related residential care sector (ARRC)

First Do No Harm Network (FDNH)

Advanced Care Planning Network (ACP)

Greater Auckland Integrated Health Network (GAIHN)

National Dementia Cooperative

MOH Dementia Project

National Health IT Board

Key achievements over 2012/13 The Health of Older People (HOP) Clinical Network has developed a strong focus and measurement around key areas such as dementia, acute hospitalisation and falls/pressure injuries. Much of this work has been successfully achieved in partnership with other networks like First Do No Harm, GAIHN and Advance Care Planning. Of note, has been establishment of a robust and formalised regional communication framework with the 200 Aged Related Residential Care (ARRC) providers throughout the northern region.

√ The network has achieved

– Strong linkages with other work programmes (i.e. National Dementia Project, FDNH & ACP Networks & GAIHN) to ensure alignment with national and regional programmes.

– A KPI reporting framework comprising several patient outcome measures. – Development of a Consumer Relationship strategy for HOP. – Supporting FDNH, DHBs and many ARRC providers to be involved in a formal

cross-sector collaborative on falls and pressure injuries. – Publication of a regional Dementia Services Guidelines Document. – Regional collaboration around Dementia Care Pathway development. – Active participation across national dementia initiatives. – Adoption of a regionally consistent Transfer of Clinical Information process

(“Yellow Envelope”) – Annual target of ACP conversations with people >65 years exceeded by second

quarter. – Enhanced understanding of interRAI capability and challenges, and defining of

regional leadership required to support ARRC and DHB sectors.



Item Health of Older People: Process/Action 2013/14


2014/15 2015/16


All DHBs will implement a dementia pathway Q4 √ √

20% reduction in falls causing major harm in those age-related residential care (ARRC) facilities that have implemented a programme.

Q3-Q4 √

75% of ARRC facilities will have implemented a falls reduction programme

Q4 √ √

20% reduction in pressure injuries in those ARRC facilities that have implemented a programme

Q3-Q4 √

Reduction in patients >75 years readmitted within 28 days Q3-Q4 √ √

32% of ARRC providers will be participating in the roll-out of interRAI

Q4 √

40% of clients receiving long term Home Based Support Services have an interRAI clinical assessment within the previous 12 months

Q4 √ √

2. Foundations

1 Recruit consumer representative to network Q1

2 Meet with each DHB HOP clinical/management team quarterly Q1-Q4

Ongoing √ √

3. Process Activity


Cognitive Impairment

3 The regional dementia working group continues to meet monthly with representation at national level

Q1-Q4 Ongoing

√ √

4 Continue to support development of DHB models of care for dementia across the region

Q1-Q4 Ongoing

√ √

5 Continue to participate in national dementia initiatives and achieving alignment with regional activities

Q1-Q4 Ongoing

√ √

6 Undertake a comprehensive stocktake of dementia service provision, initiatives & pathway elements across the region

Q1-Q2 √ √

7 Consult on, and promote use of living well with dementia plan Q1-Q2

8 Conduct a stocktake of DHB assessment and treatment criteria for delirium & make recommendations

Q3 √

9 Evaluate Australasian studies for depression & alcohol abuse for >65 and assess impacts for northern region

√ √

10 Evaluate literature for ethnicity and inequalities >65 and assess impacts for northern region

√

Quality & Safety

11 Engage additional acute and ARRC sector teams in regional Falls and Pressure Injuries Collaborative in partnership with First Do No Harm (FDNH) Network

Q1-Q4 Ongoing

√

12 Support FDNH in the measurement and reporting of improvement in harm from falls & pressure injuries

Q1-Q4 Ongoing

√

13 Implement exit strategy to incorporate reducing harm from falls & pressure injury initiatives into business as usual

√


Item Health of Older People: Process/Action 2013/14


2014/15 2015/16

14 Evaluate potential for falls/pressure injury rollout in home care support & community sectors.

√ √

15 Evaluate management of noroviruses in ARRC & opportunities for improvement

√

Medication Management

16 Reestablish HOP Regional Medication Working Group Q1

17 Evaluate after hours medication management processes in ARRC

Q2

18 Review Atlas of Variation results in older people & make recommendations

Q4 √ √

19 Partner with FDNH/HSQC on Medication Safety initiative/s Q1-Q4

Acute / Potentially Avoidable Hospitalisation

20 Evaluate regional implementation of Transfer of Clinical Information ‘yellow envelope’ in partnership with FDNH

Q2

21 Review management of residents in specialised ARRC beds to determine effective bed usage

Q1

22 Partner with GAIHN on IV/Packages of Care initiative/s Q1-Q4

interRAI

23 Establish regional governance group Q1

24 Support ARRC & monitor uptake of interRAI LTCF Q1-Q4

Ongoing √ √

25 Evaluate Dementia functionality in interRAI LTCF Q1

26 Evaluate ACP functionality in interRAI LTCF Q3

27 Evaluate Resident safety functionality in interRAI LTCF Q4

3b. Workforce

28 Review influenza vaccination uptake for ARRC workforce Q1

29 Facilitate training of Liverpool Care Pathway in ARRC Q1-Q4

30 Second Regional Dementia Coordinator position to HOP clinical network

Q1-Q4 Ongoing

√ √

31 Support GAIHN review of after hours urgent care cover for ARRC

Q1-Q4 Ongoing

√


32 Evaluate potential for roll-out of GP assessment tool for dementia across region

Q3

33 Investigate Shared Care application re Dementia care pathway Q1-Q2


34 Inform & participate in regional rehabilitation/community planning

Q1-Q4 Ongoing

√ √

35 Participate in regional ARRC bed capacity planning including the quarterly updating of ARRC contracted bed numbers

Q1-Q4 Ongoing

√ √

36 Develop guidelines on best practice dementia unit design to inform funding decisions

Q4


Mental Health & Addiction

Context

The continued growth in volume and diversity of the region’s population underpins the imperative to be constantly looking for better ways of working to meet future demand. The direction for change is improvement; improvements in responsiveness, access, outcomes that are equitable, demonstrable improvements in effectiveness and better partnerships across sectors. Rising to the Challenge - the Mental Health & Addiction Service Development Plan 2012-2017 articulates priority service development actions over the next 5 years and the Northern region carries forward a number of objectives from 2012-13.

Objectives Linkages

Our objectives are to: Continue to improve access to:

o Youth Forensic Services o Youth specialist AOD services o Eating disorders services o Regional pathway for dementia

Improve the capacity and capability of: o Adult forensic service o Services for those with high &/or

complex needs o The workforce in services for people

with high and enduring mental health needs

Improve the continuum of perinatal and infant mental health services

To improve specialist service support to primary care and other parts of the sector

Ministry of Health Statement of Intent (2012-13) and the Outcomes framework

Links with the Ministry of Health Output Plan and CI Business Plan (2012-3)

Links with the MoH Rising to the Challenge The Mental Health & Addiction Service Development Plan 2012-2017,and Blueprint 2

Links to local DHB Action Plans 2013-14

Key achievements since July 2011 Increasing sector responsiveness to children and youth at risk

The region has demonstrated increased access to Youth Forensic services Funding was secured for additional Community Youth Forensic service clinicians More than 90% of referrals to Child & Adolescent MH services are seen within 8

weeks A population-based target rate of access of children and adolescents to Specialist

Alcohol and other Drug services has been agreed Closer working relationships with local Child Youth & Family sites have been

established

Increasing service capability to respond more flexibly to support recovery DHBs are actively working with Non-Government organisations to increase service

capacity for flexibility in responsiveness to varying ranges & levels of need

Developing mental health & addiction capacity in Primary Care settings Substantial range of local projects underway Contributed to completion of GAIHN Clinical Pathway for Depression Active support has seen an increased uptake of the e-based programme for

depression

Develop capability in services for vulnerable populations E-learning workforce development solutions developed and deployed Completed analysis of current Māori workforce profile Supported the development of theregional clinical guidelines for dementia



Item Mental Health & Addiction - Process/Action 2013/14 Quarter

completed by 2014/15 2015/16


Youth Forensics

An additional 100 individuals seen by Youth Forensic services (local & regional)

Q4

tba

tba

AOD services for Adolescents & Youth

1.5% of 0-19 population in contact with specialist AOD services) by end of 2015/16

1.0%

1.25%

1.5%

Adult Forensic Psychiatry

Increasing the percentage of mentally unwell prisoner admissions to Forensic inpatient services that meet the agreed Prison Model of Care acute & sub-acute targets.

Q1 and ongoing

tba

tba


1

Adult Forensics

Explore the viability of the national KPI framework supporting the development of a Forensic KPI set

Support the development of national solutions to Forensic bed capacity issues

Q3

Q1 & ongoing

tba

tba

2

EDS Inpatient services

Review and make recommendations to adjust the model of care for the eating disorders services continuum

Review information and data needs to establish reporting benchmarks for access and outcomes

Develop an action plan from the Evaluation of EDS Implementation report, and

Work collaboratively towards an ongoing sustainable and acceptable funding solution

Q3

Q2

Q1 & ongoing

3

Improved capacity for people with high and/or complex needs

Develop and implement agreed actions from the 2012-13 regional review of the service interfaces for high & complex, that focus on:

Forensic bed flows to address Prison Waiting list issues; and

Meeting the high & complex needs in general adult services (inpatient & community)

Q3 & ongoing

tba

tba

3. Process activity


4

Youth Forensic Services

Regional Model of Care Implementation Plan including additional Community FTE in 2013-14

Work with the preferred Youth Forensic Inpatient service provider to secure regional access

Q1

Q4

5

Perinatal & Maternal MH residential services

Develop regionally consistent collaborative care planning in PIMH services for mothers and infants at risk

Develop the systems and guidelines to ensure appropriate and timely sharing of information between Maternal mental health services and other

Q1 and ongoing

Q2 and ongoing


Item Mental Health & Addiction - Process/Action 2013/14 Quarter

completed by 2014/15 2015/16

PIMH services

Work collaboratively with the MoH to develop and establish Acute & Intensive Perinatal and Infant MH service options if new funding is made available and acceptable to DHBs.

Q1 and ongoing

6

Supporting improved mental health capability and capacity in Primary Care

Develop a baseline for Consult-Liaison from the 2012-13 agreements on definition and barriers to data capture

Develop baselines on Primary MH Initiatives access and outcomes from the 2012-13 scoping work

Q2

Q3

7

Specialist AOD Services

Work with specialist AOD services (DHB & NGO) to outline what services are available and how they will contribute to the regional target across a complex case mix

Q4

8 Older Adult Services

Supporting regionally consistent deployment and application of the clinical pathway for Dementia

Q1 and ongoing

3b. Workforce

9 Work regionally to support e-learning workforce development solutions for Adult Forensics and MH Services for Older Persons being available, deployed and evaluated

Q1 and ongoing

10 Work regionally to develop flexible and sustainable after hours service delivery model for Psychiatric registrar cover

Q1 and ongoing

11 Develop and implement a Youth Forensics workforce development strategy

Q1 and ongoing

12 Implementing the EDS Workforce development plan Q3

13 Working in partnership with Te Pou and Midland region to develop a framework of service user and peer support work competencies

Q2

14 Implement any agreed regional actions from the Maori Mental Health & Addiction Workforce stock take

Q3


15 Support regionally to ensure the efficacy and efficiency of the planned upgrade to HCC

Q1 and ongoing


16

Work regionally to ensure a timely response can be provided to MoH/NHB for Youth Forensic Inpatient services that is cognisant of potential relationships with future Child Family Inpatient and Adult Forensics Inpatient environmental needs

Q1 and ongoing


Stroke

Context

The impact of strokes on individuals and their whanau / family is significant. There is a very high risk of death, and for those that survive, the disability caused by the stroke can impact on the ability to work and live independently. The disability often requires support from family and external help to support the person at significant emotional and financial cost. Strokes in the under-65 age group is particularly challenging because of the loss of income and impact on young families.

Strokes are largely preventable with improvements to lifestyle such as blood pressure control, stopping smoking, limiting alcohol intake and having a balanced diet with low salt. TIA’s also usually provide a good warning sign that a stroke is imminent. Good care of an acute stroke patient will improve the chances of survival and recovery.

Objectives Linkages

Strengthening the regional focus on stroke is designed to build on the improvements made in this region over the past few years. This is aimed to further improve the health and social outcomes for patients who have had a stroke.

The key drivers to this priority area:

Strengthen the regional focus on stroke services in key areas

Use the region’s intellectual and physical resources to improve stroke care

Avoid duplication

District Health Boards (DHB)

NZ Stroke Foundation

Greater Auckland Integrated Health Network (GAIHN)

Rehabilitation sector

Achievements since July 2012 The first (foundation) year of the Stroke RSP is progressing well, in large part due to the well- established regional stroke network (in place for close to a decade) and strong national support from the NZ Stroke Foundation.

√ Achieved – Progress against patient outcome targets – Development and implementation of stroke protocols – Regional and national collaboration with TIA Pathway development – Participation in regional rehabilitation asset planning – Directly updating and advising the Minister of Health – Strong linkages and input into national work programmes facilitated by NZ

Stroke Foundation.



Item Stroke - Process/Action

2013/14 Quarter

completed by

2014/15 2015/16

1. Stroke Measures

2013/14 targets

8% of ischaemic stroke patients thrombolysed Q1-Q4

Ongoing √ √

80% of patients who have a stroke are treated in a stroke unit Q1-Q4

Ongoing √ √

90% of patients are transferred to rehabilitation within 2 weeks Q1-Q4

Ongoing √ √


1 Strengthen the northern region stroke network, continuing to build focus on regional & national (NZ Stroke Foundation) initiatives

Q1-Q4 Ongoing

√ √

3. Process Activity


2 Ensure regional protocols for stroke patients are published to relevant intranets and accessible for clinicians

Q1

3 Further develop & rollout TIA clinical pathways across the region, in partnership with GAIHN & NZ Stroke Foundation

Q4

4 Analyse the ARCOS Study (Auckland Regional Community Stroke and leading study on ethnic differences for Maori & PI) and agree regional actions to address inequities.

Q2

5 Collect and analyse data by Maori & PI against outcome measures on a quarterly basis.

Q1

6 Develop and implement approaches to support coordination of rehabilitation services across the region

Q4 √ √

7 Develop a regional “Stroke Dashboard” of indicators Q3 √

3b. Workforce

8 All new treating physicians undergo formalised training in thrombolysis across the region

Q3 √ √

3c. Information systems

9 Assess quarterly, the % of stroke rehab patients data entered in AROC for all 4 DHBs

Q1-Q4 Ongoing

10 Report quarterly, the % of all stroke discharges coded as I64 (unspecified stroke) by each DHB

Q1-Q4

11 Investigate Shared Care application (or other, accessible by primary & secondary providers in Northern Region) re TIA care pathway

Q1-Q2


12 Inform & participate in regional rehabilitation/community planning Q1-Q4

Ongoing √ √


Informed Patient: Advance Care Planning

Context

The objective of this goal is to achieve greater patient participation and improved health care through patients being better informed across the full health spectrum; from prevention and early diagnosis to better treatment of disease. Advance care planning will ensure patients are better informed about future care and treatment choices and healthcare providers are better informed about what patient care preferences are particularly around end of life care.

Objectives Linkages


Improving patient and whanau access to ACP

Increasing health workforce awareness of and competence in ACP and communication skills

More efficient and accurate access to health information by health providers and the general public

National ACP Cooperative

Regional and national ACP tools tasks teams, project teams – across primary, secondary and tertiary care

Health of Older People work stream

Relevant NGO’s

Disability representatives

Key achievements since July 2012 Last year:

√ Over 2,000 (65% with the over 65 year age group) ACP conversations recorded across the region

√ Workforce Training: – A further 4 Level 3 Facilitators working unsupervised (total of 7 of the 9 Level 3

Facilitators now working at this level) – Developed the Basic ACP training video – Agreed Level 1 training content, developed that content and made most of it

available to the workforce – Development of the Level 3 Facilitator skill base at a two day training camp and

through ongoing Professional Development Plans – Continuous quality improvement of the Level 2 training course – Recorded statistically significant pre and post Level 2 training confidence

increases in delegates ability to undertake ACP conversations – Retained the 8 actors in the program consolidating their skills/expertise – Recruited delegates from across primary, secondary and tertiary care, and have

supported development of ACP & communication skill improvement in the regional and national healthcare workforce

– Supported the development of ACP skills in the Health of Older People work force as a regional priority

– Delivered 22 L2 Practitioner courses nationally √ Engaged with consumers through the co-design process to developed the ACP

website content √ Maori consumer tools team work undertaken to develop resources to meet the

specific needs of this population group (including two pilots in Northland) √ Asian consumer tools team work being undertaken. A resource for healthcare staff

developed and shared nationally. Additional work with Asian consumers continues. √ IT solution (CCMS) for the recording, reporting and sharing of ACP conversations and

plans is being piloted in ADHB



Item Informed Patient - Advanced Care Planning:

Process/Action

2013/14 Quarter

completed by 2014/15 2015/16


2000 ACP conversations documented Q4 √ √ Recorded hours of consumer engagement ongoing √ √

Develop and pilot patient and whanau evaluation of ACP services and resources

Q4 √

Consumer resources distributed and website hits Q4 √ √ Consumers trained to deliver CTC sessions Q4 √ √


Foundation in place, no further activity

3. Process activity


Tools and standards

1 Audit the policy and process of each regional DHB Q1 √ √

2 Assess the current tools and update/refresh where this is indicated

Q4 √ √

Improve communication and health literacy

3 Baseline measurement of ACP awareness in the 4 DHBs workforce

Q2 √ √

4 Design and roll out Phase 2 of the BOLD ACP awareness campaign

Q4 √ √

Engage capable adults/consumers

5 Engage and include the views of the disability community ongoing √ √

6

Develop a “Conversations that Count (CTC)” train-the-trainer programme

Train trainers to up skill volunteers to hold ACP sessions in the community

Facilitate community CTC sessions

Q4 √ √

Continue to development the website with consumers ongoing √ √

7

Work with consumers to:

Assess the current tools

Develop a public awareness campaign

Develop additional resources

Q4 √ √

3b. Workforce

8 Monitor use of the Basic Level training (a web-based 10 min video)

ongoing √ √

9 Complete the Level 1 training content Q2 √ √ 10 Evaluater the Level 1 training modules Q4 √ √ 11 Deliver 26 Level 2 courses equitably across the regions Q4 √ √ 12 Provide training programme administration nationally ongoing √ √ 13 Train 8 new Level 3’s Q4 √


Item Informed Patient - Advanced Care Planning:

Process/Action

2013/14 Quarter

completed by 2014/15 2015/16

14 Train 12 new actors Q2 √ 15 Support Level 3 development ongoing √ √ 16 Support existing training teams ongoing √ √ 17 Release Level 3s to train and mentor Level 2s ongoing √ √ 18 Release Level 2s to have ACP conversations ongoing √ √

Engage cultural teams

19 Continue to work with the Maori and Asian tools team ongoing √ √ 20 Develop a Pacific tools team Q2


21 Develop a regional ACP registry/electronic record Q4 √ √ 22 Alert system for recorded ACP conversations and plans Q3 √ √

Appendix A.3

Service Implementation Plan Matrices


Laboratory implementation plan

Laboratory Services in the Northern Region are delivered from DHB and private laboratories in the community setting. Key challenges in the environment include:

Growing volumes and workload being driven by population growth, an aging population and changes in clinical practice

A fragmented laboratory system with multiple laboratories in greater Auckland and in Northland

Workforce shortages in some areas coupled with pressure for sub specialisation

Increasing costs of providing services

Need to build and maintain clinical and patient confidence in all elements of the laboratory service.

Objectives Linkages

We want to ensure that the Northern Region’s population has access to a high quality clinically and financially viable laboratory service, with regionally consistent work practices. Priority is being placed on:

Ensuring effective governance arrangements are in place

Developing a robust long term direction to assist with key decision making regarding investment in laboratory facilities, effective workforce utilisation, effective management of services and future contracting arrangements

Building resilience and future proofing the laboratory system to cater for changes in clinical practice and demand

Working towards more standardised access levels and processes regionally

DHB Laboratories

Community Laboratories

Referrers

Internal & External Stakeholders

Key achievements since July 2012 Good progress has been made in strengthening the governance of community referred laboratory services and improving the working relationships between the providers of these services. DHB laboratory services are also working together in some areas to build stronger clinical linkages with initiatives including discussions regarding clinical practice, demand management etc. This foundation will be leveraged as we move forward to plan and implement changes to the delivery of community referred laboratory services.

Achievements since July 2011 include:

Review of community referred laboratory services KPIs and development of a regional dashboard

Consistent delivery against KPIs and within contractually agreed targets Progressive development and implementation of demand management strategies Sponsorship of National Schedule review and leadership/key contributors to working

groups Participation in National Roundtable to strengthen laboratory services Agreed direction for community referred laboratory services post DML contract expiry

in September 2014.



Item Laboratory services : Process/Action

13/14

Quarter due for

completion

14/15 15/16

1. Laboratory services Measures

KPI reporting as per community referred laboratory services contract Q1-Q4

Ongoing √ √

Quarterly dashboard reporting for community referred laboratory services Q1-Q4

Ongoing √ √


Establish Anatomical Pathology and Clinical Pathology Clinical Groups Q1

3. Process activity


Strengthened governance of laboratory services

1 Effective contract management with providers working to agreed KPIs Q1-Q4 √ √

2 Strong clinical oversight of all regional laboratory work Q1-Q4 √ √

3 Enhanced collaboration between the community and DHB Pathology workforce

Q1-Q4 √ √

Development of a long term model of delivery for laboratory services

4

Develop a model that supports:

• Clinically and financially viable community and hospital laboratory services

• Effective utilisation of all assets

• Retention of specialist laboratory expertise

• Cost effective service delivery

Q3 √

Smooth transition of community referred pathology services

5 Clinically lead transition team established Q1 √ √

6 Robust transition plan developed and supported by all parties to the agreement

Q1

7 Service levels defined and agreed between LabPlus and metro DHBs Q2

8 Staged transition plan implemented with minimal adverse impacts for patients, referrers and staff

Q2

Building resilience and future proofing for change

9 PC3 lab developed to support Auckland DHBs role as a national provider of TB service

TBA √

10 Timely delivery of laboratory services linked with regional pilots (e.g. bowel screening, rheumatic fever)

Ongoing

√ √

Enhanced consistency and alignment of work practices regionally

11 Timely delivery of accurate results to all referrers Ongoing

√ √

12 All laboratory service providers meeting agreed KPIs Ongoing √ √

13 Test ordering appropriate and progressively aligned with National Laboratory Schedule review recommendations

Q2 ongoing

14 Duplicate test ordering reduced through high utilisation of TestSafe Ongoing

15 Progressively aligning information systems to better support service delivery Ongoing


Item Laboratory services : Process/Action

13/14

Quarter due for

completion

14/15 15/16

3b. Workforce

16

Develop regional approaches to:

Maximise retention of and grow the laboratory workforce

Support the development of subspecialties as appropriate

Address workforce gaps where they arise

Q1-Q4

Ongoing √ √


17 Northland Laboratory Information System replacement Q3/Q4

18 Regional Laboratory e-Orders Business Case Completed Q2

19 Regional Laboratory e-Orders Implementation TBA


20 Complete business case for PC3 and LabPlus Fourth Floor Q1

21 LabPlus PC3 and Fourth Floor Development Completed TBA


Radiology implementation plan

Context

Radiology provides screening, diagnostic and treatment imaging support to other clinical services. Imaging is an integral part of healthcare. By providing diagnostic information at critical points in the patient journey, imaging services rationalise the need for intervention and target where it will have the greatest benefit.

Clinical practice is changing for radiology, driven by new models of care which sees health care increasingly being delivered in the community, and the introduction of new targets and pathways, particularly for cancer.

It is capital intensive service, particularly in high tech/high cost modalities such as CT and MR. The tight current fiscal environment means we will need to work differently to afford the projected future demand

There are also significant workforce shortages in key areas (e.g. Sonographers).

Objectives Linkages


A sustainable workforce in all Radiology related professional groups

Maximising productivity of radiology resources

Improving equitable and timely access to high quality imaging

More efficient and accurate access to health information by health providers and the public

Multiregional Radiology Group

Regional and national PET-CT variance committees

Northern Region Cancer Network

Regional Capital Group

Key achievements since July 2011 The Radiology Clinical Network was established at the end of July 2011 with cross DHB and primary care representation. It is supported by a clinical lead, Chief Medical Officer and project manager. Since inception, achievements in Radiology in the region include:

Consistent KPIs implemented, with improvements showing across most measures High level capital and asset plan, and detailed MR capacity analysis Cross-sector work to address Sonography shortage, including public and private

providers, training institutions and others Paediatric fellowship On-line paediatric Radiology clinical and technical guidelines developed and

implemented on open source PET-CT new referrals process developed and reformed Variance Committee Radiology eReferrals guidelines developed Post Implementation Review of the regional RIS/PACS Implementation of the MIRC electronic training tool for Registrars Development of a new Interventional Radiology service at Waitemata DHB Consistency of pricing and guidelines with Access to Diagnostics and Primary

Options to Acute Care



Item Radiology : Process/Action

13/14

Quarter due for

completion

14/15 15/16

1. Radiology Measures

75% validated reports completed within 24 hours Q1-Q4

Ongoing √ √

5% DNA rate for outpatient and community Q1-Q4

Ongoing √ √

85% patients receive CT scan within 6-weeks of referral Q1-Q4

Ongoing √ √

85% patients receive MR scan within 6-weeks of referral Q1-Q4

Ongoing √ √

85% patients receive Ultrasound scan within 6-weeks of referral Q1-Q4

Ongoing √ √

Track $ cost of expired inventory Q1-Q4

Ongoing √ √


Foundation in place, no further activity

3. Process activity


Radiology service planning and improvement

1 Develop Radiology Service Plan, incorporating planning principles and paediatric radiology

Q1

2 Refine and further develop Radiology Service Plan √ √

3 Review requirement to include paediatric radiology in ATD for accredited providers

Q2

4

Develop implementation plan for videoconferencing to improve the use of inter DHB videoconferencing

Principles

Requirements by DHB

Q2

Regional consistency

5 Support the development and implementation of nationally consistent RVUs

Q3-Q4 √

6 Develop and implement regionally consistent Radiology protocols for 10 common conditions

Q4 √ √

7 Provide radiology input to ATD clinical criteria Q3-Q4

8 Support the development of a single platform for community radiology referral

Q3-Q4

Ongoing √

Strengthen linkages with others

9 Continue to strengthen linkages between mutli-regional PET-CT variance committees

Q1-Q4

Ongoing √ √

10

Continue to support multi-regional radiology focus:

Chair and provide leadership to multi-regional group

Develop national initiatives in key areas

Support multi-regional focus on issues impacting radiology services

Q1-Q4

Ongoing √ √


Item Radiology : Process/Action

13/14

Quarter due for

completion

14/15 15/16

11 Continue to liaise with other groups on radiology issues, e.g. cancer network, development of clinical pathways etc

Q1-Q4 Ongoing

√ √

3b. Workforce

12 Continue to lead and develop cross sector work to address the shortage of Sonographers

Q1-Q4

Ongoing √ √

13 Support recommended options for Sonography workforce Q2-Q4

Ongoing √ √

14 Develop and implement options to support the sub-speciality radiology workforce e.g. paediatric radiology

Q3-Q4

Ongoing √ √

15 Review and implement options to address the SMO shortage in Northland DHB

Q2

16 Review Registrar positions across the region Q4


17 Advocate the expedient upgrades of Agfa PACS/RIS to a common metro Auckland platform

Q3-Q4

Ongoing √ √

18 Support the recommendations from the Post Implementation Review of the Agfa PACS/RIS

Q1-Q4

19 Implement spot checks of radiology systems across Agfa PACS/RIS and Éclair with hA

Q4 √

20 Review requirement for more clinical governance on IS systems Q4 √


21 Continue to support Business Case and asset planning and procurement processes

Q1 √ √

22 Work with hA to introduce single contracts with key suppliers Q1


Pharmacy implementation plan

Context

People need access to the right medicines at the right time and with pharmacy support according to individual need. However, population growth, our aging population and the increasing numbers of new medicines is putting increasing pressure on our ability to ensure that patients receive the right level of medication management support and costs are managed.

Commencing July 2012, the funding model for community pharmacy changed from a fee-for-item to a patient-centred model based on need rather than a ‘one size fits all’ service. In this new model, called Community Pharmacy Services Agreement (CPSA), the dispensing fees are funded from a national fixed funding envelope, and the services signal a significant change in practice whereby pharmacists provide services based on need to individual patients and will work toward becoming an integral member of the patient’s care team to improve medication safety and management.

The region will face challenges implementing the significant changes to models of pharmacy care within the large numbers of pharmacies in the region.

Objectives Linkages

This year we want to achieve:

Support the implementation of a sustainable pharmacy model, through supporting the change of practice driven by the new funding model

Support the foundations for integration of community pharmacy into primary care teams including localities.

Over the next two or three years we expect to see measurable improvements in key performance areas including:

Further development and implementation of services tailored to patient need within CPSA with a focus on improved patient outcome

Better integration of community pharmacy and the primary care sector

Pharmacist working in roles across the medication management continuum ensuring patients are not falling through the gaps at transitions of care

Progressive roll out of medications safety initiatives and e-medication management applications across the continuum of care

Community pharmacists

Hospital pharmacists

Primary care clinicians

Hospital specialist services

Primary care locality networks

PHOs

Key achievements since July 2012

- All community pharmacies in the northern region signing the new community pharmacy services agreement.

- All community pharmacies in the northern region signing the first variation of the new community services agreement.

- All PHOs supportive of the concepts in the new community pharmacy services agreement at governance level.



Item Pharmacy : Process/Action

13/14

Quarter due for completion

14/15 15/16

1. Pharmacy Measures

Community pharmacy KPI reporting as per DHBSS requirements Q1-Q4 √


1 Adequate resource to support implementation of the CPSA

3. Process activity


Pharmacy service planning and improvement

2

Support effective implementation of new pharmacy contract (CPSA) including:

- Community pharmacist communication and education encouraging integration and MDT/patient care team participation

o Develop materials

o Roll out to pharmacists

- Monitor progress against national framework and MoH audit requirements.

- Prescriber engagement (primary care via PHOs & localities and secondary care via specialist service units and hospital pharmacy)

Q1-Q4

Ongoing √ √

3

Collection and disposal of medicines waste including sharps and cytotoxics to meet safety standards:

o Procurement process scoped

o Request for selection of preferred provider(s)

o Implementation of new arrangements

Q1

Q3

Q4

√

4 Explore extension of the ‘green bag’ concept to all points of transition of care to facilitate medicines reconciliation and patient medication management and safety

Q1-Q4 √

5 Review existing Medicines Utilisation Services (MURs) with view to align with and optimise the LTC service

Q4

6 Develop a business case based on the WDHB pilot for a regionally consistent community pharmacy delivered smoking cessation service integrated with primary care and supporting the national health target

Q4

Medicines management

7 Undertake a scoping study to determine regional priorities for future implementation Q1-Q2

Regional consistency

8 Create a single Auckland metro DHB/community pharmacy advisory group to facilitate and support community pharmacist participation in locality clinical leadership teams

Q1

Strengthen linkages with others

9 Investigate the inclusion of pharmacy service provider information on Healthpoint Q1-Q4


10 Support implementation of national e-Prescription service, and local e-Med Rec (CMDHB) and e-prescribing pilots (WDHB)

Q1-Q4 Ongoing

√ √

11 Advocate for expedient upgrade for hospital e-pharmacy software (NDHB and ADHB)

Q1-Q4 Ongoing

√

12 Participate in local information sharing initiatives (TestSafe, RCD2) to ensure appropriate for pharmacy needs

Q1-Q4 Ongoing

√ √

13 Participate in national information sharing initiatives (shared care platform/s) to ensure appropriate for pharmacy needs

Q1-Q4 Ongoing

√ √


Electives implementation plan

Context

National directions place significant emphasis upon Better Sooner More Convenient elective services. Over the past three years the wait time targets for elective FSA and treatment has progressively been reduced from 6 months in 11/12, to 5 months in 12/13 and 4 months by 13/14. In addition, DHBs are working to increase the number of elective surgery cases being done.

While the Northern Region DHBs have achieved their electives targets in the past, we will be challenged to fulfil our commitment in the future. Constraints on capital funding limit our ability to build additional capacity. To be able to continue to meet our targets our DHBs have actively sought new ways to improve elective productivity within existing resources.

We are progressively standardising access and care through the development pathways for a range of clinical decisions so that most people who require elective services receive fast and consistent decisions and we have implemented a range of initiatives to improve productivity and efficiency.

We have identified a number of regional initiatives in areas where we can make the most gain by working regionally, with a strong focus on building on the work which has been done locally. We also acknowledge that elective services are managed differently in each DHB and so have focussed on initiatives which have a universal impact across our region.

Objectives Linkages

The objectives of the regional work are to:

Identify and implement the initiatives which will benefit all DHBs and assist in meeting the ESPI 2 & 5 targets

Support a more collaborative approach between our DHBs

Build on existing work and leverage those we are confident will provide the best results

Provide a more proactive and forward view of the pressure points and constraints by service and by DHB

improve equitable access to services for our population

Capacity planning

National targets

Alignment to Elective Services Contract agreed between the NHB and NDSA

The 2013/14 planning guidance for regional plans, and DHB Annual Plans.



Item Electives : Process/Action 2013/14 Quarter

completed by 2014/15 2015/16


ESPI2 targets met Q4 √

ESPI5 targets met Q4 √

52,000 total elective surgery volumes Q4

300 total bariatric surgery procedures Q4

1009 cardiac surgery procedures Q4


1 Establish Steering Group and supporting groups, with clinical leaders

Q1

2 Appoint project support Q1

3 Agree KPI measures and roles in line with NHB contract Q1

3. Process activity


Capacity and demand analysis

4 Develop capacity view Q2

5 Analysis of demand Q2

6 Develop a regionally consistent methodology for understanding utilisation

Q3

7 Agree the most critical areas across the region where focus is needed to meet the ESPI targets

Q3

Process and tools

8 Stock take production planning tools Q2

9 Identify ways telehealth and other tools can be used to support elective services

Q3

10 Agree preferred model(s) Q3

Reporting Framework

11 Develop and implement an agreed data set and reporting framework which is easily extracted, consistent, and provides a forward view of ESP reporting

Q3

12 Develop a process to review reporting dataset anc initiate action to resolve issues

Q3

Develop and Implement regional framework for elective services planning

11 Compile and agree the demand, capacity and processes and tools into a single re-usable planning framework

Q3

12 Agree process to update, improve, and reuse the framework Q4

13 Review and agree recommendations Q4

14 Develop implementation plan including resource and funding and accountabilities

Q4

15 Implement priority recommendations √


Item Electives : Process/Action 2013/14 Quarter

completed by 2014/15 2015/16

Northland pathway

16 Engage with Northland Clinicians and Managers to identify and develop a new clinical pathway with Auckland metro DHBs which will have direct benefit for the Northland patient

Q2

17 identify changes to improve processes and access Q4

18 Implement agreed changes √

eReferrals

19 Set up project, including sign contracts Q2

20 Develop detailed design specifications Q2

21 Build model Q3

22 Vendor testing Q3

23 hA and UAT testing Q4

24 Staff trained Q4

Cardiac pathway for chest pain and angiography

25 Agree consistent access pathways and triage processes Q4

26 Engage with key stakeholders in each DHB to identify barriers to implementation

Q4

27 Gap analysis of suggested changes for each DHB to implement new pathway

Q4

28 implement the preferred pathway and tools √

3b. Workforce

29 Work regionally to identify actions to establish and develop innovative initiatives which utilise the current workforce in different ways

ongoing


30 Support planning for the development of the Manukau Health Park and other DHBs capital planning, including the development of capacity and demand analysis as above

ongoing


Appendix A.4

Enablers Implementation Plan Matrix


Workforce implementation plan 2013/14 Implementation Plan

Item Workforce : Process/Action

2013/14

Quarter completed

by

2014/15 2015/16

Enable workforce flexibility and affordability to manage rising demand

1 Develop a strategy to increase flexibility, and affordability of the workforce that reflects/identifies the correct skill mix focusing on two workforce groups each year

Q1 – Q4

√

√

2

Develop a regional approach to improving workforce flexibility to better manage rising demand with a particular focus on strategies to manage demand peaks such as:

‐ Winter planning

‐ Better utilisation regional roster approaches

‐ Progressively use Trendcare (or equivalent) to inform future staffing requirements as appropriate

‐ Progressively move towards 24/7 provision as appropriate (Year 2)

Q4

√

√

Build and align the capability of the workforce to deliver new models of care

3

Conduct a stock take to understand age and skill mix, part time & full time requirements to inform future planning

o Stocktake (Year 1)

o Use information from the stocktake to determine requirements for an appropriately skilled and competent workforce (Year 2)

o Implement Agreed priorities (Year 3)

Q4

√

√

4 Increase under graduate training and new graduate employment placements in primary and community care by engaging with PHOs and Residential Care for all workforces as appropriate

√

5

Develop a regional integrated care workforce approach that is aligned to locality development

o Share learnings across the region (Year 1)

o Agree priorities for implementation (Years 2 and 3)

Q4

√

√

6

Identify opportunities to better utilise the non regulated workforce such as:

o Support the growth of cultural support roles

o Identify and support the development of potential leaders

Q3

7 Roll out level 1,2 and 3 training of Advance Care planning of 100 level 2 trainees Q1 – Q4 √ √

8 Regional DHB development and implementation of E Learning best practice and sharing of modules between subject matter experts: (target 2 modules annually)

Q4

√

√

9 Formalise feedback loops to tertiary providers regarding workforce development needs current, projected and future care models.

Q1-Q4 √ √

10 Develop workforce requirements in line with national work on the Children’s Workforce Action Plan

Q3

Grow the capacity and capability of our Maori and Pacific workforce

11

Increase the number of Maori and Pacific people by developing a dedicated regional recruitment and retention strategy (end to end support) for Maori and Pacific staff eg leadership development

o Undertake stocktake for base line data

o Agree HR metrics

o Promote and support the Nga Manukura o Apoppo Maori nurse and midwifery workforce development programme

Q4

√

12 Increase the graduate placement numbers for Maori and Pacific graduates regionally in each of nursing, midwifery, medicine and allied and technical staff

Q1 – Q4 √ √


Item Workforce : Process/Action

2013/14

Quarter completed

by

2014/15 2015/16

13 Support leadership Academy, development programmes for Maori and Pacific. Q4 √ √

14

Implement regional Kia Ora Hauora activity across the region including :

o 650 Maori or Pacific high school students enrolled in high school based programmes

o 100 Maori or Pacific people offered scholarships for tertiary health study

o 140 Maori or Pacific students offered Gateway or work experience placements within the hospital or community/ primary care provider

Q1 – Q4 √ √

Build a workforce that engages effectively with the community it serves

15

Continue building on the cultural competency training to staff members:

o 400 per DHB for CMDHB/ADHB/ WDHB staff enrolled for Culturally and Linguistically Diverse (CALD) training courses annually

o Implement new cultural competency E - Learning module at NDHB

Q1 – Q4

Q4

√

√

16 Tikanga training is included as part of mandatory training schedule for all staff Q1 – Q4 √ √

Promote advanced practise roles / working at top of scope (better, sooner more convenient)

17

Undertake new model of care delivery utilising advanced practice roles in areas such as:

o Aged Care

o Mental Health

o Diabetes

Q4 √ √

18

Work in partnership with professional leaders, primary care and unions to progressively extend scope of practice for key roles and roles where there are identified shortages such as:

o Nurse prescribing implementation eg diabetes (target to be developed)

o Identify future workforce needs to address bowel screening issues

o Progressively implement findings from the Sonograpahy pilot

o Target Thrombolysis training to relevant health care staff (target to be developed) (Develop college relationships to inform curriculum changes)

Q4 √ √

19

Support 70 people across the region to participate in Quality Improvement courses offered through Ko Awatea, Awhina and ADHB such as:

o Improvement Science in Action (Nov 2013)

o Improvement Advisor Professional Development (June 2014)

o Or other as appropriate

Q1 – Q4 √ √

Adopt a regional HR approach to developing a healthy and engaged workforce

20

Review and jointly develop HR policies & procedures/processes across the region for:

o Ongoing Immunisation of staff , improvements year on year 65% / 70% / 75%

o Standardised approach to student clinical placements and contracts

Q4 √ √

21 Design and implement a regional employee engagement tool – by health, for health.

√ √


Northern Region Training Hub 2013/14 Implementation Plan

Item Training Hub: Process/Action

2013/14

Quarter completed

by

2014/15 2015/16

Capacity: Workforce supply

1

Lead the development of consistent approaches of minimum standards for education an training across the region:

o Consolidation of training resources to ensure economies of scale and sharing of good practice by standardising at least four PGY 1 / 2 programmes annually (Aligned with national and regional service needs)

Q1 – Q4 √ √

2

Recruitment and retention of the workforce in the sector by:

o Supporting all HWNZ funded trainees to develop and implement career plans 100% and by providing access to career guidance and mentoring services for RMOs

o Coordinating clinical placements to support specialist training programmes for RMOs

Q3

Q1 - Q4

√ √

3

Analysis and reporting of regional training workforce trends

o Improve data collection/analysis for clinical workforces to improve long term planning

o Implement HSPNET for RMOs

o Administer voluntary bonding, Advanced Trainee Fellowship Scheme and other HWNZ innovations

o Maintain baseline data on Maori and Pacific health professional workforce DHBs to provide information to HWNZ funded Maori and Pacific health professionals

o Develop and implement a regional process for accessing HWNZ Maori support funding for RMOs

Q1 – Q4

√ √

Capability: Sector transformation and innovation

4

Promote and make best use of all possible training settings for entry to practice, in particular for the most vulnerable workforces. For example

o Strengthen partnership with aged care facilities

o Increase number of new graduate positions in priority service areas, ring-fencing NETP places)

o Active participation in development and support of the national skills and simulation based education strategy

Q1 – Q4 √ √

5

Promote and develop a workforce with more generic skills and is flexible to work across hospital and community settings.

o DHB placement for GPEP trainees to support integration between primary and secondary care

Q1 – Q4 √ √

Culture/Change Leadership - Engage the Workforce:

6 Support the development and implementation of NRHP workforce components Q1 - Q4

7

Foster integration between providers of undergraduate and post graduate education, professional standards organisation and employers

o Involvement of Nursing TEC’s and Schools of medicine with the development of the ACE National graduate recruitment system.

Q1 – Q4 √ √

8 Continue to develop an effective regional RMO service (such as innovative clinical placements)

Q1 –Q4 √


Information Systems Implementation Plan Strategic Information Systems Objectives for 2013/2014

(% completion of objective by quarter) baseline

13/14

Qtr1

13/14

Qtr2

13/14

Qtr3

13/14

Qtr 4

Year

14/15

Year

15/16

DHB Capital Investment Program

Quality information for Primary Healthcare

Implement Clinical Pathway Decision Support Tool

10%

30%

50%

75%

100%

Continuum of Care

eReferrals Phase 2 (Phase 1 extension + workflow)

eReferrals Phase 2.2 & 2.3 ( Internal referrals and Web

Electronic Discharge Summary to National Standards

90%

10%

25%

90%

30%

50%

10%

50%

75%

‐

70%

100%

‐

90%

‐

‐

100%

‐

Safe Medication Management

NDHB ePharmacy replacement

Roll‐out Medicine Reconciliation

CMDHB ePharmacy Business Case

10%

30%

30%

30%

25%

50%

60%

50%

80%

80%

100%

100%

100%

‐

‐

‐

‐

‐

‐

‐

Clinical Support

Develop scope and approach for Clinical Workstation

Develop business case for Clinical Workstation

Populate Clinical Documents from Northland

HCC Upgrade

Upgrade ADHB PACS to WDHB CMDHB Regional Version

Upgrade Regional RIS PACS

Complete Implementation of Perioperative Information System for WDHB (PIPMS)

Complete Implementation of Perioperative Information System for CMDHB (PCIMS)

Implement CMDHB Maternity System (National Pilot)

20%

20%

50%

‐

‐

90%

20%

50%

40%

80%

25%

25%

100%

50%

25%

100%

20%

90%

100%

50%

50%

‐

75%

50%

‐

50%

100%

‐

75%

75%

‐

100%

75%

‐

100%

‐

‐

100%

100%

‐

‐

100%

‐

‐

e‐Laboratory

Northland Laboratory Information System replacement

Regional Laboratory e‐Orders Business Case

Regional Laboratory e‐Orders Implementation

25%

20%

50%

50%

75%

100%

100%

‐

‐

‐

TBA

‐

‐

‐

‐

Regional Patient Administration System

Implementation of Northland iSoft PAS

Design of Regional Patient Administration System business case – Regional Patient Flows study

20%

30%

20%

50%

40%

75%

60%

90%

80%

100%

100%

‐

‐

Population Health Data Repository

Establish virtual regional health intelligence unit (Phase 1)

10%

30%

30%

60%

60%

90%

90%

100%

100%

‐

‐

‐

‐


Strategic Information Systems Objectives for 2013/2014

(% completion of objective by quarter) baseline

13/14

Qtr1

13/14

Qtr2

13/14

Qtr3

13/14

Qtr 4

Year

14/15

Year

15/16

Establish regional health intelligence data governance

Establish regional population health repository (Phase 1)

Implement Acute Predict in NDHB

CVD Risk Register

ECG transmissions to Éclair/Concerto

Rheumatic Fever register (Child Health)

‐

10%

10%

50%

TBA

20%

TBA

25%

100%

60%

30%

100%

40% 75% 100%

Business Report

IS Service Desk

25%

50%

75%

100%

‐

Information Systems Infrastructure & Foundations

Workspace Phase 2

New HPI /NHI integration

IS Performance Improvement Programme Phase 2 (TBD)

25%

Tba

Tba

50%

Tba%

Tba%

65%

Tba%

Tba%

85%

Tba%

Tba%

90%

‐

Tba%

100%

‐

Shared Care Plan

Shared Care rollout – Supporting Health of Older People; Localities; ACP; Diabetes; Child Health

25% 50% 75%

100%

Patient Portal

Shared Care patient portal pilot

Business Case for regional patient portal

80%

‐

90%

‐

100%

10%

‐

50%

‐

100%

‐

‐

‐

‐

National Services

National Breast Screening Phase 2 (Upgrade & consolidation of Breast Screening systems)

FPSC – Support Roll Out

‐

‐

tba%

tba%

tba%

tba%

tba%

tba%

tba%

tba%

‐

‐

‐

‐
