Auckland District Health Board - Mental Health
Introduction
This report records the results of a Surveillance Audit of a provider of hospital services against the Health and Disability Services Standards (NZS8134.1:2008; NZS8134.2:2008 and NZS8134.3:2008).
The audit has been conducted by The DAA Group Limited, an auditing agency designated under section 32 of the Health and Disability Services (Safety) Act 2001, for submission to the Ministry of Health.
The abbreviations used in this report are the same as those specified in section 10 of the Health and Disability Services (General) Standards (NZS8134.0:2008).
You can view a full copy of the standards on the Ministry of Health’s website by clicking here.
The specifics of this audit included:
Legal entity: Auckland District Health Board
Premises audited: Buchanan Rehabilitation Centre||Fraser McDonald Unit||Starship Child & Family Unit||Te Whetu Tawera
Services audited: Hospital services - Mental health services
Dates of audit: Start date: 12 May 2015 End date: 15 May 2015
Proposed changes to current services (if any): The Mental Health and Addictions Services is in the process of changing the structure of the organisation to improve community resilience, earlier intervention and a life course approach to mental disorders, increasing access for those with moderate severity disorders, greater integration of services across the health care pathway including physical health, and support for capacity building in non DHB provider services. The plan states that reducing inequities in mental health outcomes for specific populations is critical. The re-structure is creating six service groupings:
Regional Services
Local Child and Youth Community Services
Local Adult Community MHS and Segar House
Adult Inpatient Service
High and Complex Needs and Rehab Services
Services for Older Persons and Liaison Service
Each service group will be led by a Service Clinical Director who will have final point of accountability.
Secondary to this a refurbishment is to occur in the Fraser McDonald Unit and co-design work is starting in the Adult Mental Health Service and Fraser McDonald Unit.
Total beds occupied across all premises included in the audit on the first day of the audit: 124
Executive summary of the audit
Introduction
This section contains a summary of the auditors’ findings for this audit. The information is grouped into the six outcome areas contained within the Health and Disability Services Standards:
· consumer rights
· organisational management
· continuum of service delivery (the provision of services)
· safe and appropriate environment
· restraint minimisation and safe practice
· infection prevention and control.
General overview of the audit
Auckland District Health Board (ADHB) mental health and addiction services serve a population of 440,000 people. The in-patient mental health services consist of four inpatient units - Te Whetu Tawera, Fraser McDonald Unit, Buchanan Centre and the Child Family Unit. Te Whetu Tawera is a 58 bed adult acute unit comprised of three wards - Te Whitinga, which is a 23 bed ward; Te Kakenga, which is a 23 bed ward; and Te Tumanako, which is a 12 bed intensive care locked ward. The Fraser McDonald Unit is for older persons and has a 15 bed capacity. The Child Family Unit has 25 beds. The Buchanan Unit is a rehabilitation unit with 40 beds.
The organisation is currently going through a restructure. This is described as a profound change that moves the organisation to clinical leadership with one point of accountability. Additionally a new position of nurse consultant has been appointed to strengthen nursing leadership.
At the last audit there were twelve areas for improvement identified. Significant work has been undertaken to address these with eight fully addressed and now meeting the standard. Four areas remain as a ‘work in progress’ and this audit raised two new areas for improvement.
Consumer rights
Many examples of good practice were seen and discussed with staff during the course of the audit. Improvements have been made to processes around open disclosure and staff interviewed are familiar with requirements. The issues previously identified relating to open disclosure have been addressed. Staff and service users spoken to demonstrated a good understanding of the need for full and frank disclosure of information and this was exhibited in the clinical records viewed. Interpreter services are available and used when required.
The issues previously identified relating to the processes for obtaining consent have been addressed and improvements made. Processes now meet the standard required of a district health board.
The complaints process meets the requirements of legislation and is managed well. Staff, patients, and family members spoken with are aware of how they can make a complaint or how to assist in this process. The complaints process is managed by the ADHB quality team and they refer complaints to the appropriate directorate for managing, but provide system oversight.
Organisational management
After considerable consultation, a new configuration of senior roles has been developed this year in the Mental Health and Addictions Directorate. This is in keeping with a reconfiguration of responsibilities within the wider Auckland DHB. The director mental health and addictions directorate is now the single point of accountability for the directorate. There are new service groupings and some new roles, including that of service clinical director and some roles have been disestablished. The new configuration is in a transitional stage with some senior roles being filled as acting positions and some appointments yet to be made.
The quality system within the directorate is well entrenched and there is an effective system of linkages between various elements that ensures that information is appropriately reviewed and actions are identified and followed up. This reflects an improvement since the last audit in 2013. Internal audits are being conducted in all services and the information from these is reviewed and contributes to quality improvement. Incidents and complaints are recorded electronically and the follow up of these also contributes to quality improvements. Risks are identified and monitored. Extensive data is collected and analysed to inform service development and planning. There are several specific quality improvement projects addressing particular issues.
Previous gaps in policy review have been closed and there is evidence that recommendations from corrective actions are being followed up, thus resolving issues previously identified. Adverse events, including sentinel events, are recorded on the same electronic system as complaints and there is careful oversight of this at relevant levels to ensure that they are responded to appropriately and in a timely manner.
A full training and education programme is in place for all staff. The programme includes a comprehensive orientation plan for all staff with particular focus on new nursing staff and a mandatory induction process. Work has been undertaken to address credentialing and orientation issues identified at the last audit. The ability for all staff to complete ongoing training, including attendance at required training, and some support for staff, remains an issue.
Considerable improvements have been made to the nursing staff numbers following implementation and monitoring of a plan to better meet staff acuity needs. An acuity tool is used to ensure that there are sufficient nurses, based on need. Staff however report difficulty in providing additional nursing when there are specific clinical needs. Provision of sufficient social worker cover is identified as short and a plan is in the process of being implemented to address this issue.
Continuum of service delivery
Two service users’ journeys were examined and three system tracers completed. Service users’ treatment and care were reviewed at the mother and baby unit, Te Whetu Tawera intensive care and acute unit, Fraser McDonald Unit, Buchanan Rehabilitation Centre and the Starship Child and Family Unit.
Service users receive services from multidisciplinary teams of health professionals and support staff. The teams include community based service providers to ensure continuation of care, whether the service user is in an inpatient or community setting. Specialists are engaged as required. Systems are in place to implement falls prevention strategies, where appropriate. Service users that deteriorate unexpectedly receive the treatments they need in the mental health service. Assessment and screening templates reviewed were completed to inform the personal/treatment plans.
Overall, delivery of services was timely and in response to service users' needs. Personal/treatment plans reflected a holistic approach to treatment, interventions and support. Service users’ strength and self-regulation was a feature of intervention strategies, consistent with a recovery approach in mental health. Planned activities enhanced service users’ recovery goals.
Regular reviews track treatment progress and the services showed flexibility by amending treatment plans to meet the changing needs of service users. Discharge planning is a stepped process. Consideration of service users’ risk of relapse and vulnerabilities was an integral part of the discharge process.
The medicine management system meets legislative and best practice requirements. Medication safety is overseen by a mental health medicines group. Examples of ongoing improvement in medication management processes were evident. Monitoring and responses to medication effects and side effects exceeded the requirements of guidelines.
Service users and their families were satisfied with the treatment and support provided. They conveyed that the service had made a positive difference to their lives.
Four previous areas that required improvement have been addressed. Areas for improvement were identified related to delay in emergency department admission which was from the emergency department service and had been requested in a timely way from the mental health service, and monitoring of medication storage.
Areas the service excelled in related to medicines reconciliation and individual medication plans; coordination of service entry and care; initiatives to improve the physical health of service users; effective and supportive communication with service users’ families; and service user centred therapeutic relationships.
Safe and appropriate environment
Legislative requirements for the safety of the buildings are all met. Buchanan Rehabilitation Centre and the Child and Family Unit have both undergone refurbishment and this has greatly improved these environments, although this process is not yet complete at the Buchanan Rehabilitation Centre. The Fraser McDonald Unit also requires upgrading to improve consumer safety both indoors and out. The Auckland DHB has regional and national responsibilities for emergency management. A detailed review of this is currently under way.
Restraint minimisation and safe practice
No enablers are in use in the mental health and addiction services. The ‘Six Core Strategies Steering Group’ oversees the strategic approach to minimising restraint and seclusion use and there has been a significant reduction in the use of seclusion which has been used extremely rarely in the past year and the rates of seclusion of Maori are the lowest in the country. Reflective practice panels work effectively to minimise restraint use.
Infection prevention and control
The mental health and addiction service infection prevention and control (IPC) is part of the organisation wide programme. An infection prevention control nurse specialist provides support and expert advice and monitors IPC data generated from the mental health service. An IPC special interest group is being established comprised of nominated staff and IPC representative are being disestablished.
A steering committee that has representatives from all directorates of the hospital meet monthly to monitor infection prevention and control. Note: there have been no outbreaks or issues for the mental health service for the last two years.
Auckland District Health Board - Mental Health Date of Audit: 12 May 2015 Page 2 of 7