Part 3: District Health Board Governance

• Introduction
• Risk Reporting by DHBs to the Ministry
• Assurance Within DHBs on Infection Control
• Providing Assurance to Communities on Infection Control DHB Plans

Introduction

3.1
In a DHB, good governance is about ensuring that the risks associated with hospital services are managed in a responsible manner to maintain safety and public confidence. An important obligation of DHBs is to minimise the risk of infection for hospital patients, staff, and visitors.

3.2
Two key components of good governance are monitoring and reporting. In this part we examine:

• risk reporting by DHBs to the Ministry;
• arrangements within DHBs for providing assurance on infection control; and
• what assurance DHBs provide to their communities on infection control.

Risk Reporting by DHBs to the Ministry

3.3
DHBs are responsible for ensuring that publicly funded health care services are safe. In doing so, they must manage and report on financial and non-financial risks.

3.4
The Ministry has issued an Operational Policy Framework setting out detailed rules to be followed by DHBs (see Figure 3 on page 39) that include a requirement for all DHBs to comply with public sector risk management standards. DHBs are expected to report monthly to the Ministry on their management of:

• risks arising from the delivery of services and the discharge of other functions;
• risks arising from “changes in the sector”; and
• clinical effectiveness and quality.

3.5
When we examined the reports held at the Ministry as at October 2002, only a few DHBs were sending in their risk reports, and none did so every month. Some of the reports we examined contained information about risks associated with hospital-acquired infection, but none specified what action the DHB was taking to address the identified risks. Some DHBs reported the same risks in successive reports, without specifying what progress had been made in mitigating them.

3.6
Those DHBs submitting risk reports were also sending them to different groups within the Ministry. As a result, no comparative analysis was being carried out, and any issues of concern that were raised were not being routinely followed up with individual DHBs; nor was information sought where remedial action was outstanding.

3.7
In its Departmental Forecast Report for 2001-02, the Ministry undertook to report monthly to the Minister of Health on DHB financial performance and risk management. In the absence of regular reporting from individual DHBs, the Ministry acknowledged that it was not able to meet this commitment.

3.8
The Ministry told us that it intended to:

• ensure that all DHBs submitted their monthly risk reports;
• standardise the reporting format and content to require each DHB to specify measures it was taking to mitigate identified risks; and
• improve its own internal processes for monitoring DHB risk management, follow-up, and feedback.

3.9
We examined the reporting again in March 2003. The Ministry had written to DHBs on 15 November 2002 reminding them of their responsibility to submit monthly risk reports to the Ministry. Also in November 2002, the Ministry issued DHBs with a draft manual on risk management, which should provide a valuable framework for preparing risk reports. The manual covers components of clinical effectiveness and quality, including infection control.

3.10
The risk reports we reviewed on each visit to the Ministry varied widely in format and level of detail. Few referred specifically to infection control and some did not even refer to clinical effectiveness or quality. Some did not specify strategies to mitigate identified risks.

3.11
These shortcomings make it difficult for the Ministry to analyse risks throughout the health sector and present a reliable national picture to the Minister. The Ministry expects its risk management manual to be in operation from 2003-04. We would then expect all DHBs to follow a more consistent format for risk reporting.

3.12
A single group in the Ministry is now analysing the DHB risk reports, and the results are being made available to other groups (where the information is relevant to their responsibilities).

3.13
The Ministry is also using the reporting to improve communication with DHBs – to promote sharing of good practice, encourage consistent reporting, and provide a forum for raising matters of concern. Feedback is provided directly to DHBs. In addition, DHB risk managers are invited to attend a monthly meeting where the Ministry is able to raise issues and seek feedback. The meeting provides a useful forum for information exchange.

3.14
The Ministry’s February 2003 report to the Minister of Health, on DHB performance for the four months ended 31 October 2002, provided a summary of risk reports from all DHBs. It identified sector-wide risks as well as risks to individual DHBs.

Conclusions

3.15
The Ministry is addressing concerns we raised about it not receiving the required monthly risk reports from DHBs on a regular basis. Without these reports, the Ministry has no assurance that DHBs have the necessary risk management systems in place for infection control or other aspects of service delivery.

3.16
The Ministry’s actions have had some success, and it has substantially improved its monitoring of risk management in DHBs. However, the monitoring is complicated by the risk reports’ inconsistent format and level of detail, and the omission from some reports of information on measures being taken to mitigate identified risks.

3.17
The reports do not yet consistently reflect the Ministry’s draft manual on risk management. Until there is greater consistency, the Ministry cannot be sure that all DHBs are reporting all relevant risks.

3.18
The Ministry is using risk reporting to improve communication with DHBs on risk management.

Assurance Within DHBs on Infection Control

3.19
Risk management and quality assurance systems within DHBs should encompass infection control arrangements that are consistent with good practice and provide assurance about the safety of the hospital environment. In relation to infection control, DHBs have the following specific obligations:

Each DHB will safeguard consumers, staff and visitors from infection as far as is reasonably practicable. Each DHB will have environmental and hygiene management/infection control policies and procedures that minimise the likelihood of adverse health outcomes arising from infection for consumers, staff and visitors.⁴⁰

3.20
DHBs are responsible for ensuring that the providers they fund (including their own hospitals) have an appropriate quality assurance programme. Ensuring effective infection control should form part of this quality programme – for example, clinical guidelines should take account, where appropriate, of infection control matters.

3.21
Specifically in relation to infection control, DHBs should:

• know what progress hospitals are making towards meeting the Infection Control Standard by the statutory deadline (see paragraph 2.28 on page 46);
• monitor infection rates in their hospitals; and
• seek regular assurance about the quality and comprehensiveness of arrangements and activities, in order to minimise the risk of infection for patients and staff.

Boards of DHBs

3.22
To establish whether, and to what extent, DHB Boards considered infection control matters, we asked in our survey how often, and under what circumstances, infection control issues were discussed at Board meetings. We also considered the possible role of Hospital Advisory Committees (see paragraphs 3.24-3.26) in discharging this responsibility on behalf of the Board.

3.23
Boards were not receiving regular information about hospital-acquired infection rates or other aspects of infection control to provide assurance about the quality and safety of their hospital services. Senior hospital managers in most DHBs told us that their Boards considered infection control matters only when particular issues arose.⁴¹ Reporting to Boards on hospital-acquired infection rates and infection control activities was by exception, generally infrequent, and limited to major incidents or outbreaks.

Hospital Advisory Committees

3.24
Boards of DHBs are required to establish three permanent committees to advise them on matters relating to the delivery of services. One of these committees, the Hospital Advisory Committee, has three broad functions:

• to monitor the financial and operational performance of the hospital/s (and related services) of the DHB;
• to assess strategic issues relating to the provision of hospital services by or through the DHB; and
• to give the Board advice and recommendations arising from its monitoring and assessment.

3.25
Hospital Advisory Committees provide a possible means for DHBs to monitor the management of infection control in their hospitals. We reviewed selected terms of reference for Hospital Advisory Committees and minutes of committee meetings to assess the role they might play in providing assurance to the Boards of DHBs about infection control arrangements in their hospitals.

3.26
Eight DHBs reported that infection control was discussed at meetings of their Hospital Advisory Committee. This indicates the committees’ potential to support DHB Boards by overseeing infection control arrangements and monitoring rates of hospital-acquired infection. Some Boards had assigned useful roles to their Hospital Advisory Committees; for example:

• overseeing the management of clinical and operational risks;
• monitoring the containment of outbreaks;
• reporting on compliance with standards and progress towards certification;
• consideration of service-related issues such as nurse training; and
• assessing performance against service Key Performance Indicators.

Conclusions

3.27
DHB Boards were not receiving regular information about the prevention and control of hospital-acquired infection that would provide assurance that they were meeting their governance responsibilities. This suggests that DHB Boards were not giving sufficient attention to infection control as a key part of risk management and high quality health care. More DHB Boards could use their Hospital Advisory Committee to help in discharging their responsibilities for infection control.

Service Agreements between DHBs and Their Hospitals

3.28
To monitor the quality of health care services being delivered to their communities, DHBs need to have clearly defined, formal expectations about how their health care service providers (including hospitals) will manage the risks of hospital-acquired infection. We therefore expected DHBs to have specified the provision of infection control services through service agreements with their hospitals.

3.29
We asked:

• whether a service agreement required the hospital to provide infection control services;
• what information the service agreement required the hospital to collect; and
• what was done with the information collected.

3.30
Only 10 DHBs reported that the provision of infection control services was specified in a service agreement with the hospital.⁴² Those DHB hospitals were required to:

• report all cases of hospital-acquired infection; and
• prepare summarised information for reports to the Board and its quality and risk committees.

3.31
Comments made to us by DHBs with service agreements illustrated the benefits of setting formal expectations for assurance reporting, trend analysis, organisational oversight, and systems improvement.

• One DHB expected its hospital to report all instances of hospital-acquired infection to the Board monthly. The reporting provided a regular source of assurance about the safety of the hospital environment, and alerted the Board to any matters of concern.
• Formal reporting made it possible to analyse trends over time, initiate strategies to address identified weaknesses, and monitor their impact.
• Regular reports from service managers and senior hospital personnel prompted Boards to consider the wider clinical and organisational implications of infection control matters (such as for design of the hospital and its facilities).
• Reporting showed whether standards had been followed, illustrated the effectiveness of guidelines, and highlighted those areas where policies needed to be reviewed.

Conclusions

3.32
DHB Boards should include infection control in service agreements because it is an important area of risk for patient safety. However, more than half of DHBs did not include infection control in service agreements – making it less likely that hospital performance on infection control would be appropriately reported and monitored.

Providing Assurance to Communities on Infection Control

DHB Plans

3.33
DHBs must outline in their annual and strategic plans how they intend to give effect to The New Zealand Health Strategy, and other supporting strategies. In relation to infection control, the Ministry’s Integrated Approach to Infectious Disease: Priorities for Action 2002-2006 has six highest-priority disease groupings, two of which are directly relevant to the management of hospital-acquired infection (see Figure 4 on page 41). DHBs have an important part to play in addressing these priorities and implementing any related action plans. We therefore expected DHBs to demonstrate in their strategic plans how they would respond to the Ministry’s approach.

3.34
Most DHBs’ annual and/or strategic plans provided helpful information about priorities and areas of focus for infectious diseases – for example, many cited priorities for tackling respiratory infections. However, few plans commented specifically on how infection control was being applied to help reduce the rate of infections.

3.35
Certification is an important measure of the quality of systems and processes for all health care services. All licensed hospital services must be certified by 1 October 2004, but no DHB plans contained a timetable for meeting this requirement. More than two-thirds of the plans referred to voluntary accreditation (see paragraphs 2.21-2.23 on pages 44-45), which entails quality assurance processes that can help prepare for certification.

Conclusions

3.36
It was difficult to tell from DHBs’ plans how they were using infection control to help reduce rates of infectious disease. However, more than two-thirds of plans referred to voluntary accreditation – indicating an awareness among those DHBs of the importance of preparing for certification.

DHBs’ Annual Reports

3.37
DHBs must account publicly through their annual reports for the delivery of health care services to their communities. Service obligations under the Crown Funding Agreement (see Figure 3 on page 39) require them to ensure the provision of health care services that are:

• safe for patients and staff;
• consistent with their quality plans; and
• reflect a responsible approach to the management of risk.

3.38
Consistent with these obligations, we expected DHBs’ annual reports to contain:

• summarised surveillance data on rates and types of hospital-acquired infection for the previous 12 months;
• a comparison of infection rates and types with previous reporting periods to show trends, and interpretation of the results;
• commentary on DHBs’ management of any prolonged infection outbreaks that occurred over the period; and
• an outline of planned actions to address identified concerns – such as increases in infection rates or weaknesses in control systems, policies, and procedures.

3.39
We analysed each DHB’s six-month report to 30 June 2001 and their annual report for the year ended 30 June 2002.

3.40
Seventeen of the six-month reports showed the rate of hospital-acquired bloodstream infection over the 12-month period but, in the annual reports for the year ended 30 June 2002, only nine reports contained this data. Bloodstream infections are only one type of hospital-acquired infection. No DHBs published data on rates of other types of hospital-acquired infection.

3.41
Rates of hospital-acquired bloodstream infection can be expected to differ according to the size of DHB hospitals and the type of services delivered. However, performance targets for similar types of hospitals varied widely, suggesting that some DHB targets may not be realistic.

3.42
Some explanatory notes to the reports (referring, for example, to the exclusion of certain medical cases from the population measured) indicated DHBs might be using different methods for collecting and interpreting data. This raises questions about the reliability of the published rates of bloodstream infection and the validity of any comparisons of performance between DHBs.

3.43
The nature and extent of commentary varied between DHBs. Only three provided comparative data on rates of bloodstream infections over time, showing trends. Without comparative data, it is not possible for a reader to draw conclusions about a DHB’s performance. Useful commentary in some DHBs’ reports included:

• an explanation of the risk factors contributing to incidents or outbreaks;
• comparisons of rates between hospitals within the same DHB; and
• a summary of steps being taken to improve infection prevention and control.

3.44
During the reporting period, some DHBs experienced disease outbreaks related to hospital-acquired infection, creating risks for community health and generating public interest. However, the DHBs made no reference to these outbreaks in their reports.

Conclusions

3.45
DHBs’ annual reports contained limited information about infection control. The reporting was often based on unreliable and inconsistent data, raising doubts about whether targets were realistic.

3.46
In our view, the reports we examined did not provide sufficient assurance to the public on the management of hospital-acquired infection.

3.47
In the course of consulting on our report, we received comments from the Ministry and others on whether it is appropriate to include detailed material on hospital-acquired infection in DHBs’ annual reports – given the considerable number of other risk and quality issues that could potentially be reported. These comments arose out of concerns that public reporting of DHBs’ performance should not become burdensome for the DHBs, nor should it overwhelm people with excessive information. We acknowledge these concerns and have framed our recommendation accordingly.

40: Appendix 6, Provider Quality Specifications – Operational Policy Framework, 2002-03, Ministry of Health.

41: F2: Q17.

42: F2: Q10, a, b, c.