auckland district health board hospital advisory committee

Auckland District Health Board

Hospital Advisory Committee Meeting

Wednesday 1 August 2012

9.30am

A+ Trust Room

Clinical Education Centre

Level 5

Auckland City Hospital

Hei Oranga Tika Mo Te Iti Me Te Rahi Healthy Communities, Quality Healthcare

1

ATTENDANCE AND APOLOGIES

1

2

CONFLICTS OF INTEREST

3

Conf l ic ts o f In terest Quick Reference Guide

Under the NZ Public Health and Disability Act Board members must disclose all interests, and the full nature of the interest, as soon as practicable after the relevant facts come to his or her knowledge. An “interest” can include, but is not limited to:

• Being a party to, or deriving a financial benefit from, a transaction. • Having a financial interest in another party to a transaction. • Being a director, member, official, partner or trustee of another party to a transaction or a

person who will or may derive a financial benefit from it. • Being the parent, child, spouse or partner of another person or party who will or may derive a

financial benefit from the transaction. • Being otherwise directly or indirectly interested in the transaction.

If the interest is so remote or insignificant that it cannot reasonably be regarded as likely to influence the Board member in carrying out duties under the Act then he or she may not be “interested in the transaction”. The Board should generally make this decision, not the individual concerned. Gifts and offers of hospitality or sponsorship could be perceived as influencing your activities as a Board member and are unlikely to be appropriate in any circumstances.

• When a disclosure is made the Board member concerned must not take part in any deliberation or decision of the Board relating to the transaction, or be included in any quorum or decision, or sign any documents related to the transaction.

• The disclosure must be recorded in the minutes of the next meeting and entered into the interests register.

• The member can take part in deliberations (but not any decision) of the Board in relation to the transaction if the majority of other members of the Board permit the member to do so.

• If this occurs, the minutes of the meeting must record the permission given and the majority’s reasons for doing so, along with what the member said during any deliberation of the Board relating to the transaction concerned.

IMPORTANT If in doubt – declare. Ensure the full nature

of the interest is disclosed, not just the existence of the interest.

This sheet provides summary information only - refer to clause 36, schedule 3 of the New Zealand Public Health and Disability Act 2000 and the Crown Entities Act 2004 for further information (available at www.legisaltion.govt.nz) and “Managing Conflicts of Interest – Guidance for Public Entities” (www.oag.govt.nz ).

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http://www.legisaltion.govt.nz/�

http://www.oag.govt.nz/�

ADHB BOARD AND COMMITTEE (HAC) INTERESTS REGISTER

NAME OF BOARD MEMBER

ORGANISATION ROLE FINANCIAL INTEREST

NATURE OF INTEREST

DATE OF LATEST DISCLOSURE

Lester LEVY (Chair)

University of Auckland Business School New Zealand Leadership Institute Health Benefits Limited Tonkin & Taylor Waitemata District Health Board

Professor of Leadership Co-Director Deputy Chair Independent Chairman Chairman

13 June 2012

Jo AGNEW Professional Teaching Fellow, School of Nursing, Auckland University Casual Staff Nurse ADHB

Salary Salary

9 September 2011

Peter AITKEN

Pharmacist Pharmacy Care Systems Ltd Pharmacy New Lynn Medical Centre

Pharmacy Locum Shareholder/ Director, Consultant Owner

Hourly Fee

Medical Centre development and pharmacy lease

18 January 2012

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NATURE OF INTEREST


Judith BASSETT

Nil 9 December 2010

Susan BUCKLAND

Writing, editing and public relations services Medical Council of NZ Occupational Therapy Board Northern Regional Ethics Committee

Self-employed Professional Conduct Committee member Professional Conduct Committee member Member

Fees Hourly fee Hourly fee Fee

Writer, editor and public relations services Lay member of PCC set up to hear complaints brought to Medical Council and to determine outcomes Lay member of PCC to assess complaints and determine outcomes

7 August 2009

Dr Chris CHAMBERS

Employee, Auckland District Health Board Wife employed by Starship Trauma Service Clinical Senior Lecturer in Anaesthesia Auckland Clinical School Associate, Epsom Anaesthetic Group Member, ASMS Shareholder, Ormiston Surgical

20 April 2011

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NATURE OF INTEREST


Rob COOPER

Ngati Hine Health Trust James Henare Research Centre, University of Auckland Whanau Ora Governance Group National Health Board Waitemata District Health Board

Chief Executive Board Member Chair Member Member

Salary No fee Fee (to Ngati Hine Health Trust Fee (to Ngati Hine Health Trust Fee (to Ngati Hine Health Trust

Management of a Health, Disabilities, Social & Education Services Trust Advisory Assists in the development of Government’s Whanau Ora policy

25 February 2011

Lee MATHIAS

Lee Mathias Limited Midwifery and Maternity Providers Organisation Limited Pictor Limited John Seabrook Holdings Limited AuPairlink Limited

Managing Director Director Shareholder, Director Director Governance Advisor

Fee Fee paid to Lee Mathias Limited Fee No fee Fee

Shareholder, director, independent directorships and healthcare services consulting Provider of business and professional services to midwives and other maternity services providers Biotech start-up focussing on diagnostic products Estate of late husband Provider of early childhood education

22 June 2012

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Midwifery Council of New Zealand Tamaki Transformation Transitional Board Health Promotion Agency

Council member Chair Chair

Fee Fee

services contracted to the MoE. Statutory Authority

Robyn NORTHEY

Self employed Contractor Hope Foundation A+ Charitable Trust

Project management, service review, planning etc. Board member Trustee

Fee Nil

Some clients are contractors to ADHB Research and Education into Aging in NZ, Deliver Seminars and awards scholarships

20 June 2012

Gwen TEPANIA-PALMER

Waitemata District Health Board Manaia PHO Ngati Hine Health Trust Te Taitokerau Whanau Ora

Board member Board member Chair Committee member

Fee Fee

18 May 2011

Ian WARD C -4 Consulting Limited NZ Blood Service Francis Group Consultants

Principal/ Director Board Member Advisor

Fee Fee

19 January 2012

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2.0 Board and Committee Interests Schedule HAC 2012.doc



NATURE OF INTEREST


Anne KOLBE

Private Paediatric Surgical Practice Employee Communio NZ Siggins Miller, Australia Head, Auckland Clinical School, School of Medicine, University of Auckland Husband: Employee University of Auckland Risk and Audit Committee Whanganui District Health Board Pharmac Board National Health Committee

Director Senior Consultant Senior Consultant Employee Member Member Chair

Joint Owner Contractor Contractor Fee Fee Fee

28 March 2012

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3

CONFIRMATION OF MINUTES

WEDNESDAY 20 JUNE 2012

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Hospital Advisory CommitteeM i n u t e s

Minutes of the Hospital Advisory Committee meeting held on Wednesday, 20 June 2012 in the Marion Davis Library, Building 43, Auckland City Hospital, Grafton commencing at 9:30am.

1 ATTENDANCE AND APOLOGIES

The Chair declared the meeting open at 9:34am.

Committee Members Judith Bassett (Chair) Peter Aitken Susan Buckland Dr Chris Chamber Dr Lester Levy Dr Lee Mathias Gwen Tepania-Palmer Ian Ward Associate Professor Anne Kolbe

Management in Attendance Dr Margaret Wilsher – Acting Joint Chief Executive, Chief Medical Officer Margaret Dotchin – Acting Executive Director of Nursing Carolyn Simmons Carlsson - Acting Executive Director Allied Health, Scientific & Technical Brent Wiseman – Chief Financial Officer Greg Balla – Director Performance and Innovation Hilda Fa’asalele – General Manager Pacific Health Vivienne Rawlings – General Manager Human Resources Ian Bell – Board Administrator

Apologies Apologies had been received from Jo Agnew, Rob Cooper, Robyn Northey and Ngaire Buchanan.

Moved Susan Buckland, seconded Anne Kolbe That the apologies be sustained.

Carried The Chair welcomed Leah Barker, General Manager Procurement and Supply Chain Service at healthAlliance and congratulated Margaret Wilsher on her admission to The Royal Australasian College of Medical Administrators and her receiving a prize for the most outstanding candidate at the Oral Examinations.

2 CONFLICTS OF INTEREST

There were no declarations of conflicts of interest for any item on the agenda. Anne Kolbe advised that her husband, Professor John Kolbe was no longer president of the Royal Australasian College of Physicians.

3 CONFIRMATION OF MINUTES 9 MAY 2012

Moved Susan Buckland, seconded Ian Ward That the minutes of the Hospital Advisory Committee meeting held on 9 May 2012 be confirmed as a true and correct record.

Carried

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4 ACTION POINTS 9 MAY 2012

Procurement Greg Balla advised that he and Leah Barker were making good progress, with the procurement team, on developing a plan for procurement for the next few years. This plan will be distributed and will cover supply chain, procurement, and sourcing. It will be aligned to regional and national plans. Recruiting Maori and Pacific into the Health Workforce Maori and Pacific Participation in the Allied Health Professions at ADHB It was noted that the ADHB Workforce Strategy 2012 -2016 refers to 20 new Maori and Pacific graduates appointed per year, whereas in reports a percentage of the workforce is referred to. The number does seem to be ambitious as, while this referred to 20 graduates including nurses and allied health workers, the number of Maori and Pacific nurses recruited in the last year was only 3. It was suggested that what was more important was the number of Maori and Pacific student nurses in training as this will be the source to increase the number of graduates.

There is an on-line application process, managed through NoRTH, which identifies a preferred DHB and also preferred areas to work, which is then sent to the DHB although that DHB will not know where they sat in terms of the top four matched preferences. This is to avoid graduates getting multiple offers from DHBs. The applications can be sorted on ethnicity to prioritise Maori and Pacific recruitment.

It was thought that to focus on year 12-13 students may be too late and management should target younger students and relations of employees, orderlies etc as these employees already know the health system, as well as targeting particular schools.

Moved Lee Mathias; seconded Gwen Tapania-Palmer That the report on programmes and initiatives for recruiting Maori and Pacific into the health workforce be received.

Carried Gwen Tepania-Palmer considered that the approach was following the right direction but there were not the numbers there to work with. However results might be achieved by taking a multi-faceted approach which requires some guidance from that group in the workforce and also discussion with communities.

There was concern in the Northern region on the recruitment programmes so the regional HR directors were teleconferencing with the project manager as they did want applicants to go where they preferred and to have a good employment fit. There was also concern at matching preferences.

Those coming through the Tamaki Pathways to Health Careers were mainly placed in the smoke-free promotion area as they were only working in the holidays for small periods of time as a summer experience. They were mostly paid through scholarships. Internships in the holidays were a good method of getting applicants known to the DHB. Counties Manukau offered scholarships to students, who then go on to work with them as a matter of loyalty. Working at ADHB had the same loyalty effect. September intake interviews had 17 Maori of whom 5 had completed ADHB placements and 9 Pacific of whom 1 had completed a ADHB placement. The Committee asked for an update in six months.

Moved Susan Buckland; seconded Gwen Tepania-Palmer That the Maori and Pacific participation in the Allied Health professions at ADHB report be received.

Carried

While the recruitment into occupational therapy of 7 Asian and 2 Maori therapists and social work retaining 3 Asian and 1 Pacific and 2 Maori this did not reflect ADHB’s population and the target may be too low. While there was an overall plan, what was more important was an explicit operational plan to reach the targets otherwise there would not be any change. The way the

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labour market was changing may make it easier to reach targets.

5.1 Operational Performance Report

Acute flows would achieve the 95% seen within 6 hours target for the quarter but there were fluctuations. Electives were on target at 100% with a sustained effort in June. Advice to smokers to quit was 94% for April and May, and June was still being coded. There had been progress on the cardiac target through May with the waiting list now reduced to 85 and the volume target being met. There was a project on improving Intensive Care Units (ICU), incentivising surgeons and having a focused manager. Although almost double production had been achieved there was a question of sustainability as production may slow for a period until a new surgeon is available and to allow teams to rest following the effort to reach the target.

ESPI 2 had seen improvement during May and ESPI 5 would require 99 procedures over the last two weeks to achieve target which should be achieved as 120 procedures had been performed per week. There was risk of not reaching the target in a couple of paediatric services.

It was noted from the surgery reports that 25% needed rework. Surgeons should be grouped to show outliers and the report should show the number of resourced sessions targeted. Managers required this information as a management tool to be efficient and there needed to be benchmarking to see, for example, if it takes significantly longer for some teams to clean up. Reporting needed to be deeper to get better understanding.

Overall, acute demand was fairly flat although discharges had increased. Cases from other DHBs are generally more acute. While overall WIES were about 1% below plan there was a need to look at data over several years to get a better understanding of the activity with a deeper analysis of acute and elective WIES. With acute numbers being relatively stable, resources required could be reviewed. Any review should include exposure to real risks e.g. night surgery does have poorer outcomes.

Industrial Relations should look at the financial environment providing opportunities for change and opportunities to build in resilience. One of the problems suggested was that there is a constant ‘tread mill effect’, without peaks and troughs and there was not a culture of having debriefs and learnings to have real clarity and feedback to the surgeons and teams, including expectations on behaviours.

The Chair complimented management on the clear reports, noting that it appeared that target results would be achieved at the end of June.

Moved Judith Bassett; seconded Gwen Tepania-Palmer That the operational performance report be received.

Carried

5.2 Health Target Updates

The Committee acknowledged the effort going into achieving the targets. The targets were helpful, but should not be an end in themselves, but a means to an end. The new cardiac targets had yet to be determined. PHOs’ performance will be published so that communities can be informed and this was an improvement as more of the targets are becoming community based. There was active recruitment for the vacancies in radiation therapy.

8 Resolution to exclude the public from a meeting of the Hospital Advisory Meeting

Moved Lee Mathias; seconded Gwen Tepania-Palmer That the exclusion of the public from the relevant part of the meeting is necessary to enable the Board to deliberate in private on a decision or recommendation as to whether any of the grounds in paragraphs (a) to (d) of clause 32 of Schedule 3 of the Act are established in relation to all or any part of the meeting.

1. THAT the public be excluded from the following part of the proceedings of this meeting, namely consideration of items 7 to of the Agenda.

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The general subject of the matters to be considered while the public is excluded, the reason for passing this resolution in relation to each matter, and the specific grounds under the above clause for the passing of this resolution are as follows:

General subject of each matter to be considered:

Reason for passing this resolution in relation to each matter:

Ground(s) under clause 34 for the passing of this resolution:

8.1 Confidential HAC Minutes

9 May 2012 8.2 Risk 8.3 Quality

To enable the Board to carry on without prejudice or disadvantage commercial activities and negotiations: Offic ial Information Act 1982 s.9(2)(i) and s.9(2)(j)

That the public conduct of the relevant part of the meeting would be likely to result in the disclosure of information for which good reason for withholding would exist under s 9 of the Official Information Act 1982.

________________________________________________________________________

Carried The above items were discussed in public exclusion.

The meeting resumed in public for Item 6.

6 ORGAN AND TISSUE DONATION

Stephen Streat, Clinical Director Organ Donation New Zealand (ODNZ), James Judson, Medical Specialist ODNZ and Janice Langlands, Donor Coordinator were in attendance with Stephen presenting to the Committee.

The process of organ donation was outlined noting that there was a lack of understanding of the process in the community. The cause of death of deceased donors showed a decline in trauma deaths, with road deaths declining from a peak in 1997, and an increasing percentage from donors through stroke and aneurysms and others from brain death, usually older people with co-morbidities.

ODNZ did not participate in the field of live donors. Live donations had increased with further funding. No altruistic donors are accepted as the risk of their death is not acceptable. Demand for liver transplantations was increasing and was expected to peak between 2020 and 2030.

The ODNZ confidential database on all NZ ICU deaths is anonymized and has been through a rigorous ethics approval process.

There is increasing tissue donation but this is not mandated to ODNZ, as were organ donations, and in the community is not seen as a priority health need although discussions with patients before death and their discussions with the family can be very helpful.

Recording donors on drivers’ licenses was agreed by approximately 50% of the population but only about 50% of those had had prior discussions with family. If drivers had said ‘yes’ to donation there was still the need to have the family involved. The statistics show an improving societal acceptance of donation. There were difficulties in how any messages to the public on organ donation should be framed however work was being undertaken on two secondary school modules, at two levels, with the target being to educate all teenagers.

The Chair thanked the presenters. Rather than an immediate recommendation she requested that there be time to think about the presentation and to make a recommendation at the next meeting, if appropriate.

ADHB hosted the national programme of organ donation through a contract so there needed to be thought on what resources needed to be applied and prioritised to create clarity for all DHBs to support the programme with infrastructure, education and advice. What was missing was a message from the Ministry that facilitating organ donation is part of all DHBs’ core business.

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7 GENERAL BUSINESS

Results The Committee acknowledged the clinical teams’ reporting and the results being achieved.

NEXT MEETING

The meeting closed at 11:43am

The next meeting is scheduled for 9:30am, Wednesday, 1 August 2012 A+ Trust Room, Clinical Education Centre Level 5, Auckland City Hospital Grafton.

Signed as a true and correct record of the Hospital Advisory Committee meeting held on Wednesday, 20 June 2012. CHAIR: DATE:

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4

ACTION POINTS

WEDNESDAY 20 JUNE 2012

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Hospital Advisory Committee Action Points from the meeting on Wednesday 20 June 2012

Item Detail Designated Action Carried forward

Report from St John’s data on where 80+ patients go

Ngaire Buchanan August 2012 Verbal feedback

Carried forward

The plan showing the supply chain, procurement, a view of national inventory and the purchasing model to be distributed.

Greg Balla

August 2012

Carried forward

The Committee asked for a report, every second meeting, on the work being done on avoiding falls and pressure injuries.

Margaret Dotchin September 2012

4. An update on recruitment of Maori and Pacific into the work force to be provided in six months

Viv Rawlings Hilda Fa’asalele

December 2012

6. A recommendation to the Board concerning organ and tissue donation to be considered at the next meeting

Margaret Wilsher Stephen Streat

August 2012

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5

PROVIDER OPERATIONAL PERFORMANCE REPORT

5.1 Operational Performance Report

5.2 HAC Exception Report

5.3 Health Target Updates

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5 .1 Opera t iona l Per formance Repor t

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Contents (with lead HAC attendee)

1. Overview – N.Buchanan

2. Acute services performance – Dr M Wilsher

3. Elective services performance – Dr M Wilsher

4. Productivity – G Balla

4.1 Improvement projects - G Balla

4.2 Savings schedule progress - G Balla

5. Financial performance – R.Percival

Appendix 1 Operating Statement June 2012

Appendix 2 Draft Production Plan

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1. Provider Overview – Ngaire Buchanan

Health Targets

Acute flow (ED 6 hr) overall met the target for June and the 4th quarter.

Electives discharges delivered 100% to plan at the end of June.

Shorter wait times for Radiation Therapy target continued at 100%.

The result for giving advice to hospitalised smokers to quit was at 93.3% for June and 93.4% for the 4th quarter. This was a significant improvement from the previous quarter (dec-mar) 80%. This was the only provider Health Target not to be met.

Cardiac bypass surgery continued to make significant progress through June and at the end of June we met the waitlist target. 90 on the waitlist versus a target of 94.

ESPI Targets

We are confident that we met the target of having zero people waiting longer than six months for both First Surgical Assessment (ESPI 2) and for elective procedure (ESPI 5).

This still requires confirmation from the Ministry.

Financial

For the month of June:

The provider overall was $0.7 M favourable.

Provider revenue was $5.6M favourable however operating expenditure was unfavourable by $ 5.7M.

The main unfavourable variances were employee costs $5.3M and Direct treatment Cost $0.6M these are explained in detail in sections 5.3 and 5.5 respectively.

A summary P&L for June is at Appendix 1.

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2. Acute services performance – Margaret Wilsher

The table below shows the number of acute discharges (numbers of patients) this year compared to last year. Acute discharges increased by 2% over the same period last year.

Acute Patient Numbers Financial Year Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May June YTD

% change

2011 8,182 8,121 8,076 8,070 7,974 8,109 7,259 7,137 7,982 7,355 7,759 7,544 93,568 - 2012 8,109 8,176 8,282 8,024 7,724 7,794 7,306 7,388 8,352 7,761 8,212 7,911 95,039 102%

Table1: Acute discharges by month including IDF

The table below shows the Acute WIES weighted discharges by DHB versus the plan.

The major variances to plan for WDHB were Neurosurgery -350 WIES, ORL -250 WIES, Newborn services + 300 WIES, Paediactric Cardiac -271 WIES and Paediactic Orthopaedics -286 WIES.

The major variances to plan for Northland were general Surgery 114 WIES, Cardiology 222 WIES, Cardiothoracic 158 WIES and Newborn services 208 WIES.

While the provider overall was 99% to plan for acute WIES variation in timing and mix of patients impacts on the providers ability to plan and resource correctly at the service level.

Acute (WIES) 12 months to June

DHB Actual YTD Variance to Plan % of completion

ADHB 49,485 - 478 99% CMDHB 12,861 265 102% NLDHB 5,555 986 122% WDHB 17,297 - 1,613 91% Other 6,795 - 127 98% Total 91,994 - 966 99%

Table 2: Acute WIES variance to plan by DHB of domicile.

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The graph below shows the ADHB WIES versus plan over time indicating the monthly variance versus plan.

ADHB Population Acute WIES Per Month

3000

3200

3400

3600

3800

4000

4200

4400

4600

4800

Jul 0

9

Aug 09

Sep 09

Oct 09

Nov 09

Dec 09

Jan 1

0

Feb 10

Mar 10

Apr 10

May 10

Jun 1

0

Jul 1

0

Aug 10

Sep 10

Oct 10

Nov 10

Dec 10

Jan 1

1

Feb 11

Mar 11

Apr 11

May 11

Jun 1

1

Jul 1

1

Aug 11

Sep 11

Oct 11

Nov 11

Dec 11

Jan 1

2

Feb 12

Mar 12

Apr 12

May 12

Jun 1

2

Acute Contract Acute Actual

Graph 1: ADHB only WIES variance to plan

ADHB acute wies are 478 behind plan year to date, each WIES is ‘worth’ approximately $4,500. Because the revenue for the ADHB population is fixed via the population based funding mechanism, the DHB does not receive less revenue for this production (or more revenue if over-production occurs).

The following two charts show the same information for the ADHB Maori and Pacific populations.

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ADHB Acute Data - Maori

0

50

100

150

200

250

300

350

400

450

500

Jul-0

9

Sep-09

Nov-09

Jan-1

0

Mar-10

May-10

Jul-1

0

Sep-10

Nov-10

Jan-1

1

Mar-11

May-11

Jul-1

1

Sep-11

Nov-11

Jan-1

2

Mar-12

May-12

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

Acute WIES for Maori (actual) Acute WIES for Maori as % of all Acute WIES

ADHB Acute Data - Pacific

0

100

200

300

400

500

600

700

800

Jul-0

9

Sep-09

Nov-09

Jan-1

0

Mar-10

May-10

Jul-1

0

Sep-10

Nov-10

Jan-1

1

Mar-11

May-11

Jul-1

1

Sep-11

Nov-11

Jan-1

2

Mar-12

May-12

0.0%2.0%4.0%6.0%8.0%10.0%12.0%14.0%16.0%18.0%20.0%

Acute WIES for Pacific People (actual) Pacific People WIES as % of all Acute WIES

Interpretation Note:- The charts above represent a view of ADHB population treated at ACH, not a comprehensive population view which would incorporate the ADHB population treated at other hospitals. The 8% for Maori and 16% for Pacific represent the approximate relative proportions of ADHB population.

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3. Elective Performance – Margaret Wilsher

3.1 Elective Discharge and WIES performance

The table below shows the elective discharges in total, (includes IDF), by month compared to last year. The overall change was 1%

Elective Patient Numbers Financial Year Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May June YTD

% change

2011 1,879 1,886 1,812 1,823 2,006 1,622 1,131 2,084 2,271 1,999 2,311 2,152 22,976 - 2012 1,823 2,054 2,113 1,815 2,147 1,694 1,205 2,002 2,291 1,736 2,268 2,110 23,258 101%

Below is a table that shows overall elective WIES (weighted discharges) versus the original plan. This shows that ADHB delivered to plan.

Overall – Elective WIES for 12 months to June 2012

DHB Actual YTD Variance to Plan % of completion

ADHB 14,967 - 979 94% CMDHB 5,454 - 40 99% NLDHB 2,080 - 216 91% WDHB 7,508 821 112% Other 4,104 448 112% Total 34,113 34 100%

The following charts and tables show the cumulative variance in volumes versus the plan. While the provider overall was 100% to plan for elective WIES variation in timing and mix of patients impacts on the providers ability to plan and resource correctly at the service level.

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Auckland DHB - WIES

Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12

Cumulative Original Plan 1,366.8 2,863.8 4,295.6 5,597.4 7,029.2 8,005.5 9,242.2 10,543.9 11,975.8 13,147.3 14,644.3 15,946.0

Cumulative Current Plan 1,244.3 2,677.9 4,065.9 5,339.2 6,788.8 7,896.3 8,746.1 10,116.8 11,691.1 12,920.3 14,515.0 15,946.0

Cumulative Actual WIES 1,164.8 2,418.8 3,828.8 5,013.3 6,376.4 7,650.1 8,313.2 9,574.0 11,059.1 12,191.3 13,612.6 14,966.8

Cumulative Actual WIES Variance -79.4 -259.1 -237.1 -325.9 -412.3 -246.1 -432.9 -542.8 -632.0 -729.0 -902.4 -979.2

% Plan Achieved 94% 90% 94% 94% 94% 97% 95% 95% 95% 94% 94% 94%

% Coded 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Elective Cumulative Inpatient WIES VolumesFor Auckland DHB

For 01 July 2011 to 30 June 2012

0

2000

4000

6000

8000

10000

12000

14000

16000

18000


Original Plan VolumeCurrent Plan VolumeActual WIES

Because funding for ADHB’s population is on the basis of a population based funding formula, an underperformance on ADHB elective WIES is not a revenue risk, except if it is matched by an underperformance on the Health Targets which have revenue attached (and for which the revenue is calculated on the basis of WIES production).

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Counties Manukau – planned and actual WIES


Cumulative Original Plan 470.9 986.6 1,479.9 1,928.3 2,421.6 2,757.9 3,184.0 3,632.4 4,125.7 4,529.3 5,045.0 5,493.4

Cumulative Current Plan 428.7 922.5 1,400.7 1,839.4 2,338.8 2,720.3 3,013.1 3,485.3 4,027.6 4,451.1 5,000.5 5,493.4

Cumulative Actual WIES 375.8 860.5 1,303.9 1,769.3 2,256.3 2,625.5 2,957.6 3,396.6 4,007.8 4,348.5 4,915.5 5,453.8

Cumulative Actual WIES Variance -52.8 -62.0 -96.8 -70.1 -82.5 -94.8 -55.5 -88.7 -19.8 -102.6 -85.0 -39.7

% Plan Achieved 88% 93% 93% 96% 96% 97% 98% 97% 100% 98% 98% 99%

% Coded 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Elective Cumulative Inpatient WIES VolumesFor Counties Manukau DHB


0

1000

2000

3000

4000

5000

6000



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Northland – planned and actual WIES


Cumulative Original Plan 196.8 412.4 618.5 806.0 1,012.2 1,152.7 1,330.8 1,518.3 1,724.4 1,893.1 2,108.7 2,296.1

Cumulative Current Plan 179.2 385.6 585.5 768.8 977.5 1,137.0 1,259.4 1,456.8 1,683.4 1,860.4 2,090.1 2,296.1

Cumulative Actual WIES 117.7 273.4 534.4 710.6 992.7 1,194.0 1,268.9 1,442.1 1,604.6 1,749.7 1,914.7 2,080.3

Cumulative Actual WIES Variance -61.5 -112.2 -51.1 -58.2 15.1 57.0 9.5 -14.7 -78.8 -110.8 -175.3 -215.8

% Plan Achieved 66% 71% 91% 92% 102% 105% 101% 99% 95% 94% 92% 91%

% Coded 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Elective Cumulative Inpatient WIES VolumesFor Northland DHB


0

500

1000

1500

2000

2500



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Waitemata – planned and actual WIES


Cumulative Original Plan 580.3 1,215.9 1,823.9 2,376.6 2,984.6 3,399.1 3,924.2 4,476.9 5,084.9 5,582.3 6,217.9 6,770.6

Cumulative Current Plan 521.8 1,123.0 1,705.1 2,239.0 2,846.9 3,311.4 3,667.7 4,242.5 4,902.8 5,418.2 6,087.0 6,687.1

Cumulative Actual WIES 620.9 1,252.8 1,881.8 2,491.5 3,198.0 3,796.6 4,160.3 4,773.9 5,494.6 6,173.4 6,847.8 7,507.6

Cumulative Actual WIES Variance 99.1 129.8 176.8 252.5 351.1 485.3 492.5 531.4 591.8 755.2 760.8 820.5

% Plan Achieved 119% 112% 110% 111% 112% 115% 113% 113% 112% 114% 112% 112%

% Coded 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Elective Cumulative Inpatient WIES VolumesFor Waitemata DHB


0

1000

2000

3000

4000

5000

6000

7000

8000



38

Top and Bottom Three Elective Services for Auckland Population

The following table is a presentation of the top and bottom 3 elective services for ADHB’s own population (by variance in WIES). The variance from plan is shown in wies and this is converted to approximate patient numbers in the final column.

Plan Actual Variance Variance Average wies

per Variance Top 3 wies wies wies % Patient Patients ORL 874 989 115 13% 1.1 100 Cardiology 717 783 66 9% 1.3 49 Vascular Surgery 471 522 52 11% 2.2 24 Bottom 3 General Surgery 3,327 2,962 -365 -11% 1.5 -250 Cardiothoracic 1,256 1,006 -250 -20% 6.7 -38 Orthopaedics 3,490 3,335 -154 -4% 2.8 -55

Top and Bottom Three Elective Services for CMDHB Population


per Variance Top 3 wies wies wies % Patient Patients Neurosurgery 348 467 119 34% 4.2 28 General Surgery 145 248 103 71% 2.2 46 Paediatric Orthopaedics 165 259 93 56% 3.1 30 Bottom 3 Paediatric Cardiac 403 252 -151 -37% 2.5 -61 Cardiothoracic 1,529 1,392 -137 -9% 6.5 -21 Oral Health 450 361 -89 -20% 0.4 -205

39

Top and Bottom Three Elective Services for NDHB Population


per Variance Top 3 wies wies wies % Patient Patients Neurosurgery 126 232 106 84% 4.5 24 Vascular Surgery 215 269 53 25% 3.0 18 Paediatric Cardiac 52 86 34 66% 3.2 11 Bottom 3 Cardiothoracic 802 632 -170 -21% 6.7 -25 Cardiology 413 328 -85 -21% 1.5 -56 Paediatric Orthopaedics 137 56 -81 -59% 1.6 -52

Top and Bottom Three Elective Services for WDHB Population


per Variance Top 3 wies wies wies % Patient Patients Ophthalmology 1,143 1,431 288 25% 0.6 500 Paediatric Orthopaedics 347 533 187 54% 1.6 115 Neurosurgery 413 573 159 39% 4.0 40 Bottom 3 Paediatric Cardiac 315 254 -61 -19% 2.1 -29 Oral Health 359 305 -53 -15% 0.4 -124 Vascular Surgery 708 656 -51 -7% 2.5 -21

40

3.2 Elective Discharges Performance Health Target by Service.

We have met the target for 2011/12. (Note: we are still completing final reconciliation.). This result is a 7% increase in discharges over last year.

The table below shows ADHB’s performance against the elective discharge health target by service.

41

3.3 ESPI Performance

ESPI 2: First specialist assessment performance

An ADHB Annual Plan objective was to have no patients are waiting over 6 months for first specialist assessment, FSA, by 30 June 2012.

We are confident that we have met this target. Final confirmation from the Ministry of health is expected by the middle of August.

The organisation is now focused on the revised target of having no patient waiting over 5 months for a first specialist assessment, FSA, by 30 June 2013.

The graph below shows the waitlist profile for EPSI 2. (Note: this excludes patients that have been deferred for medical reasons and patients that have requested a later date.)

First specialist assessments (FSA) are an important component of the elective flow. Patients having an FSA may be referred to a surgical wait-list, but they may also be managed medically and in some cases a decision may be made that no treatment is required. This has implication for production planning in that an increase of 100 in a

42

target for surgical discharges may require an additional 200 – 300 FSAs to provide 100 additional surgical cases on the wait-list. For production planning purposes an assessment has been made service by service of the conversion rate of surgical service FSAs to the surgical waitlist. For General Surgery, for example, we estimate that some 70% of FSAs result in a referral to the surgical waitlist. Medical service FSAs do not typically result in referrals to a wait list but may do for example in respect of medical services closely associated with a surgical service e.g. Cardiology.

The table which follows has the actual FSA’s and the variance to plan for the Northern Region DHBs (main IDF customers).The period covered is the twelve months to June 2012.

DHB Year to Date June

Actual Variance %

Complete ADHB 50,265 869 102% CMDHB 11,428 - 875 93% NLDHB 998 - 246 80% WDHB 19,357 - 224 99% Other 1,675 - 42 98%

83,723 - 518 99%

Table: First Specialist Assessment Volumes vs Plan

43

ESPI 5 Performance Zero Patients Waiting Over 6 Months for Elective Procedure

An ADHB Annual Plan objective was to have no patients waiting over 6 months for an elective procedure by 30 June 2012.

We are confident that we met the target. Final confirmation from the Ministry of Health is expected by the middle of August.

The chart below shows the profile for ESPI 5. Note it excludes patients that have been deferred for medical reason or have requested a later date.

Interpretation Note – Wait time penalties

NHB has written to ADHB advising that from 1 July 2012 all patients are to be seen within 6 months and that the following estimated buffers will apply from 1 July 2012, clinics 40 patients and surgery 50 patients

The NHB current policy is that where a DHB is non-compliant (ie patients waiting > 6 months) on 3 consecutive months (or any 5 months in a year) the DHB will be penalised 1/12th of its additional elective revenue for each month of non-compliance with a minimum of 2 months.

ADHB’s annual additional elective revenue is approximately $24m per annum therefore a penalty of over $2m per month or minimum of $4m is at risk..

ADHB did not receive a wait time penalty and the full additional elective revenue of $23,964,772 was received. ADHB should also receive the additional revenue for meeting the ESPI targets of approximately $0.9M. This includes the share of the regional payment.

44

3.4 OR Performance Statistics

OR management maintain and report on a wide range of operational KPIs. Included among these is elective theatre utilisation. The benchmark figure for OR utilisation is 85%.

Adjusted utilization =

(total time patients are in theatre+ clean up time+ set up time)/ Total resourced minutes

3.5 Greenlane Surgical Unit Production

GSU elective discharge outputs (expressed as discharges per working day).

We have maintained a level of output through June that reflects the resourcing allocated to the GSU.

Planning and implementation of actions has begun to increase production at Greenlane in line with the business case approved by the audit and finance committee July 11, 2012 and the production plan.

45

Elective Surgical Discharges per Working Day at Greenlane (All populations)

25

27

29

31

33

35

37

39

41

43

Jul-1

0

Aug-10

Sep-10

Oct-10

Nov-10

Dec-10

Jan-11

Feb-11

Mar-11

Apr-11

May-11

Jun-11

Jul-1

1

Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12

Apr-12

May-12

Jun-12

actual

3.6 Overall comments on elective surgery.

While we achieved the ESPI and Elective discharges results for year 2011/12 we have initiated a review of the systems, responsibilities and reporting framework as we are not satisfied with the way we needed to manage to deliver this result. The output from this review will be linked to other improvement activity already underway as part of the surgical performance program. We expect that this review will show significant change is required in the way we book and schedule patients, the way we manage a change in a patients appointment and the visibility of a patients status as they move through the system.

One of the changes we have been implementing through the surgical performance program is an improved production planning framework. (POP) This framework is intended to connect annual, monthly, weekly and daily routines and provide visibility of plan performance. To date this framework has been implemented at the monthly time horizon for 13 surgical services and the weekly routines are being trialed in orthopedics and general surgery.

We have a draft annual elective surgery production plan (POP) that is currently going through an approval process, by service, healthcare service group and then organization. (Note this should occur in Nov-Dec to line up with budget cycles) This is the first time we have had a plan with assumptions documented in this way. This plan is the starting point to track delivery against assumptions and is built to deliver the many factors that we need to consider including, ESPI’s at 5 months, overall discharge and WIES targets, bed availability, holiday periods and flows from FSA’s to surgical lists. We do expect to see variation to this plan the key is to use the defined management routines

46

to understand the variation adjust the plan and escalate issues as appropriate. These routines and escalations are defined in the framework.

A copy of the organization level summary of this plan is attached as an appendix 2 for your information.

47

4. Productivity – Greg Balla

4.1 Improvement projects

In the Annual Plan ADHB has committed to 133 improvement activities.

54 of these are listed in goal 2 “Performance Improvement”.

Overall progress for these 54 projects is good. 27 projects are implementing solutions or monitoring the implemented solutions. This is what you should expect at this time of the year. A further 19 have finished and are delivering the anticipated benefits.

5 projects are running behind plan, including the Oracle FMIS system upgrade, Bereavement project, appointment of the clinical leaders, introducing a staff engagement tool and developing the process for engaging consumers formally in service redesign or development. The last two projects have been delayed to support achieving zero deficit.

The two projects over budget are the finance management system upgrade (oracle) and the CRIS clinical information records project.

See table next page for overall phasing of projects in goal 2.

48

The table below shows the overall status of projects committed to in the 11/12 district annual plan. Group Pack Report DAP Projects - total projects: 133

Goal

Number Started Current Phase On Time On Budget

Expected Outcome

Finished

Post Implementation Benefits

Plan Do/

Check Act Cancelled Green Orange Red Green Orange Red Green Orange Red Green Orange Red Define Measure Analyse Improve Control

1 Lift the Health of the people in Auckland City

53 53 5 1 10 18 12 0 41 4 1 45 0 1 45 1 0 7 7 0 0

2 Performance improvement

54 54 2 0 6 22 5 0 30 5 0 33 2 0 34 1 0 19 19 0 0

3 Live within our means

26 26 1 4 4 4 5 0 16 2 0 15 2 1 17 1 0 8 7 1 0

Total # 133 133 8 5 20 44 22 0 87 11 1 93 4 2 96 3 1 34 33 1 0

Total % 100% 100% 6% 4% 15% 33% 17% 0% 65% 8% 1% 70% 3% 2% 72% 2% 1% 26% 25% 1% 0%

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4.2 Savings schedule progress

Category Gains June Gains Year to date $000 $000 Direct treatment costs 482 6,583 FTE Productivity 2,774 20,924 Indirect treatment costs 552 7,905 Total gains achieved 3,808 35,412

Direct Treatment Costs ($ 6,583 Year to Date) The main contributors to Direct Treatment Savings YTD are Procurement savings locked in by ADHB Materials Management effective this financial year of $2,529 and reduction in blood usage through a reduction in unnecessary usage of blood of $2,507. FTE Productivity ($20,9240 Year to Date) The major contributor to this is the Releasing Time to Care Programme which was operating in 35 wards to December increasing to 41 in January and is achieving an additional 7% direct patient contact time for on average 33 nurses a ward $4,918. Reducing length of stay has contributed to a better patient experience and saved bed days valued at $3,686. Daily Rapid Rounds in Orthopaedics and improved patient flow in Starship also contributed $1,908 and $1,552 from improved management of patients. Indirect Treatment Costs ($7,905 Year to Date) Improved contract pricing from the ex ADHB Materials Management is now reported as savings attributed to Health Benefits but the benefit is a saving to ADHB. Year to date this amounts to $7,122

50

5. Financial Performance – Rosalie Percival

5.1 Overview

The provider arm was favourable to the revised budget for the month by $0.7m. YTD is $18.7m unfavourable.

Actual Month

Variance Month

Actual YTD

Variance YTD

$k $k $k $k

Income 106,021 5,550 F 1,210,803 2,785 F

Operating Expenditure 99,231 (5,762) U 1,144,375 (24,743) U

Operating Surplus/(Deficit) 6,790 (212) U 66,428 (21,958) U

Non-Operating Expenditure 7,068 960 F 90,474 3,275 F

Total Surplus / (Deficit) (278) 748 F (24,046) (18,683) U

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5.2 Revenue

Category Variance Month

Variance YTD Explanation of major Items (YTD)

$M $M MOH - Base Funding 1.4 (0.6) Unfavourable IDF revenue $(1.3)m and

favourable population-based revenue $0.7m.

Funding Subcontract Revenue

0.7 0.9 Biochemical Genetic revenue favourable $1.3m, favourable Public Health Revenue $0.1m offset by unfavourable funding subcontract revenue $(0.5)m

Other Patient Care Revenue

2.2 0.4 Unfavourable non-NZ resident revenue $(2.5)m and lower ACC revenue $(0.9)m offset by higher Inter-provider Revenue $2.6m and Other Government Revenue $1.2m.

Sales of Service and Product

0.2 (0.7) ADHB Trust receipts, research income, and accommodation rental all reported favourable income which is offset by lower Lab and Blood revenue and clinical engineering contract revenue.

Clinical Education & Training

0.3 0.9 Higher than expected number of clinical trainees.

Financial Income 0.3 1.7 Gain on mark to market valuation of interest rate swaps.

Trust & Donation Income

0.5 1.0 Favourable Trust revenue following the receipt of the Ernst & Marion Davis Library Collection $0.9m.

Other Income (0.2) (0.8) Lower than expected clinical and non-clinical miscellaneous revenue.

5.5 2.8

52

5.3 Workforce

The tables below analyses the FTE numbers and variance both in numbers and value for the month and year to date.

Employee Group

Actual FTE

Month

Variance FTE

Month Variance

Month

Actual FTE YTD

Variance FTE YTD

Variance YTD

# # $k # # $k

Medical 1,220 2 F (4,175) U 1,205 10 F (10,259) U

Nursing 3,294 23 F (1,677) U 3,322 11 F (5,159) U

Technical 1,773 66 F (358) U 1,797 46 F (671) U

Hotel Services 219 8 F (30) U 227 (1) U (546) U

Administration 1,144 73 F 80 F 1,156 57 F 1,534 F

Other 2 0 F 1 F 1 0 F 13 F

Total (excl Outsourced Staff)

7,652 172 F (6,159) U 7,710 123 F (15,089) U

Outsourced staff 105 (65) U (516) U 92 (52) U (4,125) U

Total (incl Outsourced Staff)

7,757 107 F (6,675) U 7,802 71 F (19,214) U

Other Staff Related Costs

1,366 F (1,344) U

Total Employee Costs 7,757 107 F (5,309) U 7,802 71 F (20,558) U

Employee Group

Actual FTE

Month

Variance FTE

Month Variance

Month

Actual FTE YTD

Variance FTE YTD

Variance YTD

# # $k # # $k

Operational 6,253 69 F (3,957) U 6,293 32 F (20,294) U

Mental Health 707 24 F (786) U 724 11 F (1,421) U

Ancillary Services 797 15 F (566) U 785 28 F 1,157 F

Total Employee Costs 7,757 107 F (5,309) U 7,802 71 F (20,558) U

53

FTE

June FTEs are 107 below budget and 28 lower than May.

By category, Medical, Nursing, Technical, Hotel Services and Administration FTE are below budget offset by outsourced staff FTE which is above budget.

Employee Costs

The financial variance for the month of June of $5.3m U is explained below:

Medical $4,175k U - The unfavourable variance is primarily driven by SMO job size cost $2,490k U made up of Cardiac HSG $1,630k, Children’s HSG $670k and Cancer & Blood HSG $190k as well as Adult HSG RMO over-appointments, Perioperative Services and Children’s HSG unachieved budget savings and the use of locums to cover SMO and RMO vacancies in Mental Health. Nursing $1,677k U - The unfavourable variance is primarily due to the unachieved budget savings in Children’s HSG and Perioperative Services $506k U, impact of the PSA 2% lump sum payout $422k U and budget phasing of NZNO settlement phased evenly over the year.

Technical $358 U -The unfavourable variance is mainly due to the back pay provision for unsettled IEA staff $270k U.

Outsourced Staff $516k U - The key variances for the month are Medical contractors $67k U, Allied Health $99k U and Management & Admin contractors $370k U, primarily due to temporary staff across all HSGs. Other Staff Related Costs $1,366k F - The key variances for the month are Retirement Gratuities/Long Service Leave and Sick Leave provision $1,375k F (due to year-end revaluations of these employee benefits), ACC Levy $504k F (adjustment in the rates applied with 2012/13 levy rates lower than 2011/2012), offset by unfavourable superannuation costs $311k U and JRMO expenses $171k U.

54

5.4 Clinical Services Outsourcing Costs

Outsourcing costs were $616k U for the month. YTD is $2,976k U.

Outsourcing activity continued in order to achieve ADHB population elective discharge targets. The key areas of higher expenditure for the year to date against budget are in Paediatric Surgery and Operations - Radiology as explained below. The higher level of activity has enabled us to meet the full year targets of 11,950 discharges. Specific commentary regarding the year to date areas of expenditure:

Children’s HSG $2,056k U - this relates to procedures which were budgeted to be performed at GSU but because GSU has not been ready for use these procedures have had to be outsourced.

Operations (excl ORA) $1,509k U - the unfavourable variance is mainly driven by PET scans – continued demand is greater than contracted volumes.

• PET scans $946k U (current YTD actuals $1,254k versus last year $749k ie an increase of 67%).

• MRI $269k U- budget assumption of lower outsourcing due to increased in-house throughput has been substantially, but not fully, achieved.

Biochemical Genetics $1051k U - greater volumes for Maternal Serum Screening contract $904k U - offset by additional MOH funding, bottom line neutral. Research $322k U - the unfavourable variance is fully funded and is bottom line neutral.

Mental Health $522k F- mainly due to the transfer of outsourced costs for Keith House to the MH Funder $380k F, savings in flexifund costs $113k F and savings in Primary-Secondary continuum of care project costs $71k F.

Adult HSG $553k F - the favourable variance is in elective surgery outsourcing which has been managed across the organisation in order to achieve full year targets.

Cardiac HSG $1,119k F - Cardiac Services has maintained a favourable variance for the year through maximising the throughput in hospital bypass cases, and minimising the volumes required to be sent to other facilities.

55

5.5 Direct Treatment Costs

Direct treatment costs are unfavourable to budget at $604k F for the month and unfavourable to budget at $1,552k U YTD.

Within this there are four key variances YTD, as follows:

Category Variance

YTD

($k) Explanation of major items YTD

Drugs 3,101 F Cancer & Blood HSG $2,753k F - reflects the lower demand for Haemophilia blood products $1,941k F (equal offset in revenue) together with savings in Oncology and Haematology driven by lower chemotherapy volumes $812k F. Perioperative Services $1,421 F - the favourable variances are across all major drug lines. Actual costs are 10% higher than last YTD reflecting increased activity. With GSU still to deliver in full, costs have not reached budget.

Adult HSG $721k F - the key variance is for Renal Fluids $483k F reflecting lower peritoneal dialysis volumes – this is offset by higher clinical supplies costs as more patients are managed on haemodialysis.

Operations $589k U - the unfavourable variance is due to budgeted savings in Pharmacy from the implementation of the in-house chemotherapy production unit. The unfavourable variance reported here is offset by favourable variances in Cancer & Blood due to lower drug costs.

Children’s HSG $513k U – mainly use of blood products in Paediatric Medical (Haematology/Oncology) and PICU. The Haematology/Oncology usage is $400k higher than 2011/12 reflecting a change in patient mix and complexity.

Cardiac HSG $463k U- increased usage of cardiovascular specific drugs, IV solutions and blood products, driven mainly by the high level of activity within the service.

Women’s & Genetics HSG $113k U - mainly blood products and hormones - fluctuating use compared with last year and volume driven.

Drug costs were also lower than budget across the provider services due to the change in accounting policy to treat Imprest Pharmacy as inventory rather than expense $0.9m (included in the favourable variances identified above).

56

Category Variance

YTD

($k) Explanation of major items YTD

Clinical Supplies

(4,475) U Cardiac HSG $2,132k U - the major variance is the service target savings budgeted within clinical supplies Perioperative Services $1,330k U - actual costs are 12% higher than last year reflecting increased activity and unachieved budget savings of $1.4m.

Complementary Services $987k U - Research and LabPlus national services - both fully funded.

Operations & Clinical Support $551k U - predominantly in Radiology reflecting costs for complex interventional radiology patients - volumes are above budget assumption.

Chemical & Media

450 F Operations & Clinical Support $267k F - represents 1.4% of YTD budget, reflecting volumes lower than budget for recent months.

Patient Appliances

(941) U Children’s HSG $542k U - mainly Implants $567k U.- Paediatric Surgical $322k U relates to elective surgery volumes and Paediatric Cardiac $242k U relates to change in accounting treatment for Melody valves from 1 July (cost now not on billed - collected via Wies) and increased activity with ICDs, Pacemakers and valves.

Cardiac HSG $454 k U – ongoing high usage of ICDs, Pacemakers and other Cardiac implants directly related to the high activity within the service.

57

Annual Production Plan Appendix Period: 1 July 2012 – 30 June 2013 Area: Surgery View: Organisation Level Date published: 29th June 2012 Contents

1. GSU summary of session increases for FY 12/13 2. GSU proposed schedule 3. Summary of all theatre sessions by service

58

1. GSU summary of session increases for FY 12/13

59

2. G

SU Proposed schedule

60

3. Summary of all theatre sessions by service

61

Appendix 1 Provider Operating Statement June 2012 and YTD

$k Jun-12 YTD

Actual Budget Variance Actual Budget Variance

Income

ADHB Funder Sourced 88,699 87,304 1,394 F 1,044,519 1,045,075 (556) U

MoH Sourced (Incl CTA) 5,654 4,614 1,040 F 52,898 51,130 1,767 F

Other Income 10,583 8,295 2,287 F 97,698 98,821 (1,124) U

Trust & Donation Income 959 472 487 F 5,139 4,163 976 F

Financial Income 126 (215) 341 F 10,550 8,828 1,722 F

106,021 100,471 5,550 F 1,210,803 1,208,018 2,785 F

Expenditure

Employee Costs 65,929 61,137 (4,792) U 748,510 732,078 (16,433) U

Outsourced Staff 4,195 3,679 (516) U 48,665 44,540 (4,125) U

Outsourced Clinical Services 3,802 3,186 (616) U 38,960 35,983 (2,976) U

Treatment Costs - Direct 15,729 16,333 604 F 199,206 197,653 (1,552) U

Treatment Costs - Indirect 3,395 3,443 48 F 42,391 41,740 (650) U

Other Costs 6,180 5,692 (488) U 66,644 67,638 993 F

Total Operating Expenditure 99,231 93,469 (5,762) U 1,144,375 1,119,632 (24,743) U

Operating Contribution 6,790 7,002 (212) U 66,428 88,386 (21,958) U

Depreciation, Interest & Capital Charge

7,068 8,028 960 F 90,474 93,749 3,275 F

Net Surplus / (Deficit) (278) (1,025) 748 F (24,046) (5,363) (18,683) U

62

5 .2 H AC Except ion Repor t

63

HAC Exception Report June 2012

B61. Raw Elective Surgical Daycase RateThis is an area of concern. A service by service review will need to be undertaken to get this back on track.

B63. Mental Health Percentage of people with relapse prevention plansAlthough sitting below lower exception line, Relapse Planning compliance remains on target at 95%.

B61. Raw Elective Surgical Daycase Rate

40%

45%

50%

55%

60%

65%

70%

75%

Jun-

10

Aug-

10

Oct

-10

Dec

-10

Feb-

11

Apr-1

1

Jun-

11

Aug-

11

Oct

-11

Dec

-11

Feb-

12

Apr-1

2

Jun-

12

B63. Mental Health Percentage of people with relapse prevention plans

0.94

0.95

0.96

0.97

0.98

0.99

1

Jun-

10

Aug-

10

Oct

-10

Dec-

10

Feb-

11

Apr-1

1

Jun-

11

Aug-

11

Oct

-11

Dec-

11

Feb-

12

Apr-1

2

Jun-

12

65

5 .3 Hea l th Target Updates

67

5 .2 Hospi ta l Ad visory Commi t tee Hea l th Target Updates The summary of our performance against the Health targets is set out below.

4 of the targets have been met for June and the Better help for smokers to quit is just below the target.

Acute flow (6hr ED target). Winter is continuing to be challenging with high numbers overall and high peak loads. Short term focus is mainly on time to be seen by medical staff although we are still experiencing bed block occasionally.

Elective surgery achieved the target for 2011/2012.

Better help for smokers to quit is now on track to deliver with significant improvement in the last two qtrs.

Shorter waits for radiation therapy delivered to target.

A very good performance from the cardiac team, increasing overall volume delivery and reduce the waiting list. The target was met for the year..

Status Comment

Adult and Child acute patient flow 95% achieved for June. Qtr Adults 94%

and qtr Children’s 96%. Qtr Overall 95%

Improved access to elective surgery 100 %YTD end June. 7% growth over

last year.

Shorter waits for radiation therapy 100% for March. 100% for Qtr.

Better help for smokers to quit

June 93.3 %. Qtr 93.4%.Target 95%.

Cardiac bypass surgery 90 patients waiting against a 94 target at year end.

Key to symbols

Proceeding to plan

Issues being addressed

Target unlikely to be met

69

Project: Primary Objective: That at least 95% of patients will be admitted, discharged or transferred from Auckland Emergency Departments within 6 hours

Date of Delivery: 30 June 2012

Project Risks / Comments:Shorter Stays in ED reported 95% of patients admitted, discharged or transferred for the quarter ending 30th

June 2012. Adult Emergency Department is now progressing phase one performance initiative review to ensure changes already introduced have been sustained, and the establishment of phase 2 initiatives to lift performance to 96-97& average.

Acute Patient Flow, Actual vs Target, July 2010 - June 2012

0%

20%

40%

60%

80%

100%

Jul-2

010

Aug-

2010

Sep-

2010

Oct

-201

0N

ov-2

010

Dec

-201

0

Jan-

2011

Feb-

2011

Mar

-201

1Ap

r-20

11

May

-201

1Ju

n-20

11Ju

l-201

1Au

g-20

11

Sep-

2011

Oct

-201

1N

ov-2

011

Dec

-201

1

Jan-

2012

Feb-

2012

Mar

-201

2Ap

r-20

12

May

-201

2Ju

n-20

12

Actual Goal MOH Target

70

Project: Adult Acute Patient FlowPrimary Objective: That at least 95% of patients will be admitted, discharged or transferred from Auckland Adult Emergency Department within 6 hoursDate of Delivery: 30 June 2012Clinical Leads: Nurse Director Jane Lees , Dr Tim ParkeProject Sponsor: Nurse Director Margaret DotchinSteering Group: Nurse Director Margaret Dotchin, General Manager Ngaire Buchanan,Dr Tim Parke, Dr Art Nahill, Dr Wayne Jones, Dr Andrew Old

Improvements to date:Streamlined AED processes and measurement and manage the challenge of growing demandReviewed Medical / Nursing requirements for AED and approved business case for resource increase to match increased workload.Charge nurse patient flow coordinator introducedImproved access to Radiology Streamlined documentation required for safe transfer Improved triage processes.Managing bed block with additional resources58 Additional beds opened 2009-2010 Winter Ward 31 General Medicine 10 additional beds August – October 2010Managing bed block & reducing the time patients wait through improved processes and teamworkDaily Rapid Rounds introduced in General Medicine (Feb 2010) and Orthopaedics (July 2010)Nurse Facilitated Discharging in General Medicine (April 2010)Improved Bed Management Communication via Estimated Discharge Dates, CMS upgrades, improved visual management, more efficient bed management meetings, earlier time of day discharging.Daily breech review meetings to understand root causes and implement short term solutions.Immediate actions to improve performance:1. Increased engagement of Senior Leadership Team to support improvement

activities and reduce road blocks to improvement.Increase communication and engagement of Clinical Directors, SMO’s, RMO’s Increase communication and engagement of Charge Nurses and RN’s after hours to further reduce wait times for patient transfer from Emergency DepartmentEngage with SMO’s, RMO’s and nurses one to one, by CD, Nurse Advisor or Level 2 clinical leader where resistance to required behaviour is demonstrated.Valuing patient time poster campaign

2. Establish ED short stay unitImplement APU flex beds Improve measurement of Ready to Go patients in EDComplete recruitment of remaining ED resource to improve weekend coverageSupport General Medicine by diversion of patients to subspecialtiesImplement general surgery acute flow team initiatives to improve response timeCMO to attend Orthopaedic SMO meeting to increase engagement.Relocate bed manager to ED after hours Implement ED discharge nurse on weekendHands on support of ED flow Charge Nurse to reduce roadblocks to timely review and transfer of patientsCommence physiotherapy facilitated discharge in Orthopaedics.Establish discharge co-ordination responsibility in Gen Med ward nursing team.Further increase timely overnight transfers from ED to inpatient wards once bed allocated.

3. Five day rapid improvement event planned for April to focus on improvement of process from decision to admit to patient transfer complete.Improve elective scheduling.

Project Risks / Comments:Adults quarter end was 94%. There have been periods of inconsistency of performance against the target during the

quarter. Analysis of the inconsistency has been undertaken at the daily breech meeting. Actions taken to improve performance include General Medical Clinical Director presence at the breech meeting and/or communicating and escalating detail of breeches to the relevant service. Escalating ‘ near’ breeches to relevant teams within General Medicine especially when late sign on times have occurred. Agreement to progress with phase 2 of acute adult flow project using a DAMIC approach addressing the 3 and 2 hours sign on time, currently this is in define stage.

Adult Acute Patient Flow, Actual vs Target, July 2010 - June 2012

0%

20%

40%

60%

80%

100%

Jul-2

010

Aug-

2010

Sep-

2010

Oct

-201

0N

ov-2

010

Dec

-201

0Ja

n-20

11Fe

b-20

11M

ar-2

011

Apr-

2011

May

-201

1Ju

n-20

11Ju

l-201

1Au

g-20

11Se

p-20

11

Oct

-201

1N

ov-2

011

Dec

-201

1Ja

n-20

12Fe

b-20

12M

ar-2

012

Apr-

2012

May

-201

2Ju

n-20

12


1

23

71

Project: Children’s Acute Patient FlowPrimary Objective: That at least 95% of patients will be admitted, discharged or transferred from Auckland Children’s EmergencyDepartment within 6 hoursDate of Delivery: 30 June 2012Clinical Lead: Richard AickinProject Sponsor: Fionnagh DouganSteering Group Fionnagh Dougan, Richard Aickin, Michael Shepherd, Janet Campbell, Stuart Dalziel

Improvements to date:• Increased completion and accuracy of Estimate

Discharge Date (EDD’s) for current inpatients• Improvement in the forecasting of short term

occupancy levels• Changes to the call back registrar guidelines to

improve timeliness of patient review• Capacity planning project commenced to ensure

better longer term planning• Bed turnaround reviewed which has resulted in a

reduction of time taken • Moved ward reviews to outpatient area to free bed

spaces• Cohorted patients with low complexity and reduced

staffing for this group, freeing staff to care for increasing numbers of higher acuity patients

• Rostered additional senior staff onto periods of high admissions, to improve decision-making speed

Project Risks /Comments:Performance remains in control and continues to be sustained above the target levels. Staff shortages and increased early winter demand has made achievement of the target more challenging, however the quarter end position was 96%. Improvements made to date have been embedded.

During the coming year there will be a continued focus on improving targeted areas to ensure that performance remains comfortably above 95%.

Children's Acute Patient Flow, Actual vs Target, July 2010 - June 2012

0%

20%

40%

60%

80%

100%

Jul-2

010

Aug-

2010

Sep-

2010

Oct

-201

0N

ov-2

010

Dec

-201

0

Jan-

2011

Feb-

2011

Mar

-201

1Ap

r-20

11M

ay-2

011

Jun-

2011

Jul-2

011

Aug-

2011

Sep-

2011

Oct

-201

1N

ov-2

011

Dec

-201

1

Jan-

2012

Feb-

2012

Mar

-201

2Ap

r-20

12M

ay-2

012

Jun-

2012


72

Project: Improved access to elective surgeryPrimary Objective: Increase ADHB Elective Surgical Discharges from 11,149 to 11,950Date of Delivery: 30 June 2012Clinical Lead: Vanessa Beavis, Ian CivilProject Sponsor: Ngaire BuchananSteering Group: Ngaire Buchanan, Dr Vanessa Beavis, Margaret Dotchin, Fionnagh Dougan, Ian Civil.

Risks / Comments: (Amber)

1.Year to date May we are at 99.6% to target. Note: This includes the following that are yet to be coded. 100 skins, 30 orthopedic outsourced patients, 40 Avastins and 20 general recodes.2. Outsourcing continues for Pediatric general surgery, Orthopedics and Cardiac 3. Ophthalmology continues with weekend lists.

Planned activities: ADHB Elective Discharges

97%97%

102%101%

100% 100%100% 100%

99% 98%99%

100%

-

2,000

4,000

6,000

8,000

10,000

12,000

14,000

July August September October November December January February March April May June

Dis

char

ges

80.00%

85.00%

90.00%

95.00%

100.00%

105.00%

110.00%

% o

f Hea

lth ta

rget

YTD

cum actual cum % cum plan

second highest number of outsource ADHB discharges ever in a single month

73

Project: Shorter waits for Radiation TherapyPrimary Objective: That 100% of eligible patients requiring radiation treatment will commence treatment within 4 weeks of a decision to treat from 31 December 2010. Date of Delivery: 30 June 2012 (4 weeks)Clinical Lead: Giuseppe SassoProject Sponsor: Robyn DunninghamSteering Group: Robyn Dunningham, Giuseppe Sasso, Robyn Dunningham

Radiation Oncology Wait times – June 2012

In June 100% of eligible patients were treated within the 4 week target timeline.

Ongoing initiatives to maintain the 4 week target

A public/private Model of care enables our clinicians to treat public patients at ARO. The service is only outsourcing as required to meet the 28 day target.

Introduction of new technology: The introduction of V-Mat treatment has the potential to reduce treatment times for specific tumour groups by up to 50% when fullyimplemented mid 2012.

Aria project: A project is well underway to develop a full electronic record within the LINAC machine’s operating system. Project end has been further extended following delays to the ARIA software upgrade. The upgrade was finalised in early March with the project due to be completed by July 2012.

An “Operational team” measures KPI’s to prioritise the waitlist and analyse performance on a weekly basis. This is ongoing.

A daily Waitlist report enables daily monitoring and immediate remedial action if required. This is ongoing.

The service is 100% compliant for June 2012

Key risks which may impact capacity to deliver to the target in the coming months:1. Ongoing Radiation therapist vacancies may impact our treatment capacity2. The current Pinnacle planning software is due to be upgraded and replacement software is

currently being evaluated. The current platform limits the number of complex patients able to be planned at any one time.

3. Pre- booked HDR Brachytherapy is limiting the number of Linac Treatment slots available.

Radiation Therapy - % patients commencing treatment w ithin 4 weeks of FSA, Actual vs Target, July 2010 - June 2012

75%

80%

85%

90%

95%

100%

105%

Jul-2

010

Aug-

2010

Sep-

2010

Oct

-201

0N

ov-2

010

Dec

-201

0Ja

n-20

11Fe

b-20

11M

ar-2

011

Apr-

2011

May

-201

1Ju

n-20

11Ju

l-201

1Au

g-20

11Se

p-20

11

Oct

-201

1N

ov-2

011

Dec

-201

1Ja

n-20

12Fe

b-20

12M

ar-2

012

Apr-

2012

May

-201

2Ju

n-20

12


74

Achievements :• World Smokefree Day promotions based on the theme “it’s About

Whanau” will took place in the week of the 28th May

Immediate Actions to improve performance A. Focus on short stay/high volume areas to achieve • AED and APU continue to monitor and maintain performance B. Improve engagement of clinical workforce to achieve • Reports on events discharged and coded in the month to be

available for services and reported weekly to OMM and Board• To work with Registrars to determine barriers and support

mechanisms to assist junior doctors complete the ABC in clinical documents and EDS

C. Data collection systems and processes to achieve• Smoking and Brief advice column to be added to Ward electronic

whiteboards to monitor the ABC completion• Investigation of generation of a Brief Advice Brochure with the EDS

for AED• Research – ADHB joining 7 other DHBs is participating in a ABC

Outcomes survey funded by the MOH to measure the outcomes of Brief Advice given in hospitals- Final results out in June

• Final coding decision in contradictory cases to be based on Discharge Letter smoking status and brief advice

D. Communications – planned activities• An NRT working Group as been established to develop an NRT

promotion campaign to all clinical staff

CommentsResult: the result for June was 93.3% with 933 of the 1000 smokers recorded with brief advice. The final result for quarter 4 was 93.4%Through a very busy time the Emergency Department maintained a good result. Weekly checks of all results were undertaken in June and feedback given to the small number of wards that had missed brief advice. Spot chart audits were completed in Adult Health during the month. Investigation into a system for capturing patients who are discharged directly from ACH theatres is underway. The number of smokers in this group is small but contributes to deficit. The function to enable generation of a brief advice letter for all smokers with the Electronic Discharge Summary from AED and APU - similar to Waitemata DHB - is currently being tested and is due to go live by mid July.The ABC Outcomes survey results are to be published at ADHB in early July. The survey results were very positive. 77% of the 412 patients surveyed recalled receiving brief advice and of those that made a quit attempt 33% were quit at 4 weeks. The ADHB results showed that 87% recalled the advice, 82% made a quit attempt and of those 51% were quit at 4 weeks.

Project: Better help for smokers to quitObjective : 95% of hospitalised smokers provided advice and help to quit by 1/07/2012Clinical Lead: Stephen Child Programme Sponsor: Margaret Dotchin Programme Manager: Jan Marshall Steering Group: Di Roud, Anna Schofield, Maggie O’Brien, Stephen Child, George Laking, Jim Kriechbaum, Paul Bohmer, Arun Kulkarni, Michelle Stevens, Kristine Nicol, Bernadette Rehman, Paul Birch, Anne-Marie Pickering, Michael Haw, Jan Marshall, Kara Hamilton, Steven Stewart

Better help for smokers -% of hospitalised smokers provided advice and help to quit, Actual vs Target, Jan 2011-Jun 2012 and % of Maori

hospitalized smokers offered advice and support to quit

0%10%20%30%40%50%60%70%80%90%

100%

Jan-

2011

Feb-

2011

Mar

-201

1

Apr-

2011

May

-201

1

Jun-

2011

Jul-2

011

Aug-

2011

Sep-

2011

Oct

-201

1

Nov

-201

1

Dec

-201

1

Jan-

2012

Feb-

2012

Mar

-201

2

Apr-

2012

May

-201

2

Jun-

2012

Actual Goal MOH Target Actual - Maori

75

Project: Cardiac Bypass SurgeryPrimary Objectives: To enable timely access to cardiac bypass surgery the waiting list should be no greater than 94.

To support the national cardiac bypass intervention target, 940 bypasses should be completed in 2011/2012Date of Delivery: 30 June 2012Clinical Lead: Peter RuygrokProject Sponsor: Peter LowrySteering Group: Paget Milsom, Andrew McKee, Peter Ruygrok, Elizabeth Shaw, Pam Freeman

Completed Improvement Activities: Developed and implemented electronic scheduling system Initiated pre-admit process Developed detailed operational reporting Set up development production process Approved business case for CVICU bed capacity Built capacity planning model for CVICU and Ward 42 Developed patient load planning tool Initiated daily bed management meeting Enhanced recovery pathway in ICU Scheduling workshop for productive theatres Releasing time to care foundation modules CVICU\HDU merger ICU Nursing FTE business case approved Rapid Rounds ward 42

Further improvements in progress:. 3 in a row bypass\Dovetailing (productive list)

Optimise the theatre schedule by planning a “productive list” ECMO – Resource planning process

To improve resource planning and day to day processes to reduce the impact of high ECMO demand on bypass cases

The Productive Operating Room (NHS Programme)To increase productivity and improve safety in theatre through

better co-ordination and removal of waste and frustrations

Delay to discharge – ward 42 & CVICUTo reduce LOS for patients who are delayed during the discharge

process, reducing theatre cancellations• Elective patient pathway

To maintain elective throughput in the service during periods of constrained production

• Weekend contract case certainty• Increasing capacity\delivery 4th theatre project• Surgical outcome database• Surgical site infection reduction project

Monthly PerformanceJune was a very good month in terms of throughput for the service with 85 procedures delivered against a plan of 80. In addition to these volumes the service has been able to complete the MoH contracted volumes for the year as well as achieving ESPI compliance. Total eligible bypass production to the northern region has increased from 883 cases to 943 cases comparing this financial year to last. Of these 60 additional cases 24 cases were provided internally at ACH. 10 additional “cardiac other” procedures were also delivered from within ACH when comparing this time period.

The service is now planning for next year and has completed work on the standard week that the various theatre teams will staff to. The additions to the theatre nursing team are yet to complete their induction program with the service and therefore the 4th theatre will not be able to be consistently opened until November. Due to this the service plans to outsource additional cases at the start of the year and to reduce volumes once the more cost efficient internal capacity comes online. The elective pathway work is continuing with patients being booked through pre admit clinic for their surgery. As this process matures within the service we will review further opportunities it provides such as a DOSA process.

Reduce Cardiac Waiting List, Actual vs Target, Jan 2011 - Jun 2013

0

20

40

60

80

100

120

140

160

Jan-

2011

Feb-

2011

Mar

-201

1Ap

r-20

11M

ay-2

011

Jun-

2011

Jul-2

011

Aug-

2011

Sep-

2011

Oct

-201

1N

ov-2

011

Dec

-201

1Ja

n-20

12Fe

b-20

12M

ar-2

012

Apr-

2012

May

-201

2Ju

n-20

12Ju

l-201

2Au

g-20

12Se

p-20

12O

ct-2

012

Nov

-201

2D

ec-2

012

Jan-

2013

Feb-

2013

Mar

-201

3Ap

r-20

13M

ay-2

013

Jun-

2013


76

6

GENERAL BUSINESS

77

7

RESOLUTION TO EXCLUDE THE PUBLIC FROM A MEETING OF THE HOSPITAL

ADVISORY MEETING

7.1 Resolution to exclude the public

79

AUCKLAND DISTRICT HEALTH BOARD

RESOLUTION TO EXCLUDE THE PUBLIC

FROM A MEETING OF THE HOSPITAL ADVISORY MEETING

Clauses 32 and 33, Schedule 3, New Zealand Public Health and Disability Act 2000 (“Act”)

That the exclusion of the public from the relevant part of the meeting is necessary to enable the Board to deliberate in private on a decision or recommendation as to whether any of the grounds in paragraphs (a) to (d) of clause 32 of Schedule 3 of the Act are established in relation to all or any part of the meeting. 1. THAT the public be excluded from the following part of the proceedings of this meeting, namely consideration of items 7 to of the Agenda. The general subject of the matters to be considered while the public is excluded, the reason for passing this resolution in relation to each matter, and the specific grounds under the above clause for the passing of this resolution are as follows: General subject of each matter to be considered:

Reason for passing this resolution in relation to each matter:

Ground(s) under clause 34 for the passing of this resolution:

7.1 Confidential HAC Minutes 20 June 2012 7.2 Risk 7.3 Quality

7.4 Starship Refurbishment –

Update

To enable the Board to carry on without prejudice or disadvantage commercial activities and negotiations: Official Information Act 1982 s.9(2)(i) and s.9(2)(j)

That the public conduct of the relevant part of the meeting would be likely to result in the disclosure of information for which good reason for withholding would exist under s 9 of the Official Information Act 1982.

Hospital Advisory Committee

A g e n d a

MEETING DETAILS

Time and Date 9:30am – 12:30pm, Wednesday 1 August 2012

Venue A+ Trust Room, Level 5, Clinical Education Centre, Auckland City Hospital

Members Judith Bassett (Chair), Jo Agnew, Peter Aitken, Susan Buckland, Rob Cooper, Dr Chris Chambers, Dr Lester Levy, Dr Lee Mathias, Robyn Northey, Gwen Tepania-Palmer, Ian Ward, Assoc Prof Anne Kolbe.

Apologies Lester Levy

In Attendance Ngaire Buchanan, Dr Margaret Wilsher, Rosalie Percival, Margaret Dotchin, Sue Waters, Greg Balla, Hilda Faasalele, Vivienne Rawlings, Ian Bell.

COMMITTEE FUNCTIONS

To monitor the financial and operational performance of the hospitals and related services of the DHB, assess strategic issues relating to the provision of hospital services by or through the DHB and give the Board advice and recommendations on that monitoring and that assessment.

Item Page No

1

2m to 9:32am

Attendance and Apologies 001

2

3m to 9:35am

Conflicts of Interest 003

3

5m to 9:40am

Confirmation of Minutes Wednesday 20 June 2012 013

4

5m to 9:45am

Action Points Wednesday 20 June 2012 021

5

40m 15m to 10:40am

Provider Operational Performance Report

5.1 Operational Performance Report 5.2 HAC Exception Report 5.3 Health Target Updates

025

027 063 067

6

5m to 10:45am

General Business 077

Hospital Advisory Committee Agenda – Wednesday 5 October 2011 Page 1

Hospital Advisory Committee Agenda – Wednesday 5 October 2011 Page 2

7

20m to 11:05am

Resolution to exclude the public from a meeting of the Hospital Advisory Meeting

7.1 Resolution to exclude the public

079

NEXT MEETING

Time and Date: 9.30am, Wednesday, 12 September 2012

Venue: A+ Trust Room, Level 5, Clinical Education Centre, Auckland City Hospital

Hei Oranga Tika Mo Te Iti Me Te Rahi

Healthy Communities, Quality Healthcare

auckland district health board hospital advisory committee

Documents