The National Asset Management Programme for district health boards Report 1: The current-state assessment June 2020 The National Asset Management Programme for district health boards Report 1: The current-state assessment June 2020 Released 2020 health.govt.nz Acknowledgements The Ministry of Health thanks the staff involved from the 20 district health boards, Beca Group Ltd and Chow Hill Architects Ltd for their contribution to the completion of this draft current-state assessment of assets in New Zealand district health boards. Citation: Ministry of Health. 2020. The National Asset Management Programme for district health boards. Report 1: The draft current-state assessment. Wellington: Ministry of Health. Published in June 2020 by the Ministry of Health PO Box 5013, Wellington 6140, New Zealand ISBN 978-1-98-859794-2 (print) ISBN 978-1-98-859795-9 (online) This document is available at health.govt.nz This work is licensed under the Creative Commons Attribution 4.0 International licence. In essence, you are free to: share ie, copy and redistribute the material in any medium or format; adapt ie, remix, transform and build upon the material. You must give appropriate credit, provide a link to the licence and indicate if changes were made. Contents National asset management programme documents 3 Asset management source documents 4 Executive summary 5 Section 1 Introduction 12 Section 3 Clinical facilities’ fitness-for-purpose 37 Section 4 Information technology 54 Conclusion and next steps 67 References 71 Appendix 1 DHB abbreviations 72 Appendix 2 Scope, data confidence and reliability 73 Appendix 3 CFFFP gross floor areas 77 Appendix 4 Expert assessments for infrastructure 81 List of Figures Figure 1: Asset management maturity assessed by Morrison Low in 2018 ........................ 15 Figure 2: Aggregation of asset information through planning levels .................................... 18 Figure 3: NAMP, asset management and investment decisions .............................................. 19 Figure 4: Mean age of major campus buildings for all 20 DHBs ............................................. 24 Figure 5: Mean building condition scores weighted for gross floor area ............................ 24 Figure 6: Mean condition scores for buildings that house mental health units ................ 25 Figure 7: Importance level of buildings and degree of earthquake risk (%NBS)............... 26 Figure 8: Risk levels of seismic restraints as a proportion of buildings................................. 27 Figure 9: Risk levels for presence of asbestos as a proportion of buildings ....................... 28 Figure 10: Levels of risk for passive fire separation as a proportion of buildings ............. 29 Figure 11: Mean condition for sitewide electrical infrastructure at 30 campuses............. 34 Figure 12: Mean condition for sitewide mechanical infrastructure at 31 campuses ........ 34 Figure 13: Mean scores on nine design principles for mental health units ......................... 41 Figure 14: Mean scores on nine design principles for emergency departments .............. 44 Figure 15: Mean scores on nine design principles for operating theatre suites................ 46 Figure 16: Mean scores on nine design principles for intensive care units ......................... 49 Figure 17: Mean scores on nine design principles for inpatient units ................................... 51 THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS 1 Figure 18: Assessment scores for financial management systems .......................................... 60 Figure 19: Assessment scores for patient administration systems .......................................... 60 Figure 20: Assessment scores for pharmacy management systems....................................... 61 Figure 21: Assessment scores for clinical portals ........................................................................... 62 Figure 22: Assessment scores for electronic medication charts ............................................... 62 List of Tables Table 1: Scope of 2019 asset assessments Table 2: Assessment components for buildings Table 3: Assessment components for sitewide infrastructure Table 4: Condition score definitions for building and infrastructure Table 5: The 24 buildings housing clinical facilities with poor condition scores Table 6: 10 buildings with the poorest condition scores Table 7: Health facility new build cost estimates Table 8: Health facility refurbishment cost estimates Table 9: The 80 units assessed for CFFFP Table 10: Rating definitions for CFFFP assessments Table 11: Data sources for health digital technology assessments Table 12: Access barriers to clinical information and collegial communication Table 13: IT asset condition and deployment assessment scores Table 14: Asset scope for the second NAMP report due in 2022 Table 15: Confidence grades for 2019 sources of assessment data Table 16: Reliability of data for building and infrastructure assessments Table 17: Data completeness for building and infrastructure assessments Table 18: Scope of 2019 building and infrastructure assessments Table 19: Completeness of datasets for 2019 CFFFP assessements Table 20: Gross floor area analysis for emergency departments Table 21: Gross floor area analysis for intensive care units Table 22: Gross floor area analysis for operating theatres Table 23: Gross floor area analysis for inpatient units Table 24: Gross floor area analysis for mental health units 2 THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS 8 21 22 23 30 32 36 36 38 39 56 58 59 68 73 73 74 75 76 77 78 78 79 80 National asset management programme documents Author Title Date Beca Group NAMP lessons learnt workshop 1 2019 Rider Levett Bucknall All-in ROC estimates 2019 Beca Group Kestral Group NAMP methodology for rating seismic resilience Background information on seismic risk and seismic assessment 2019 2019 Beca Group NAMP DHB2 asset condition self-assessment: Data standard and methodology 2019 Beca Group 31 DHB campus assessment reports 2019 Ministry of Health 20 DHB clinical facility fitness-for-purpose reports 2019 Ministry of Health Workshops: Introduction to asset management: Writing, living, updating asset management plans 2019 Ministry of Health Clinical facility fitness-for-purpose: Assessment tool and methodology NAMP asset condition survey: Data standard and methodology 2019 Ministry of Health NAMP updates for district health boards 2018-19 Morrison Low National asset register: Feasibility report 2018 DHB Working Group Asset conditions workshop presentation 2018 Ministry of Health Guidelines for critical and priority buildings and infrastructure in the district health boards and the health sector 2018 Ministry of Health Asset management plan: Project management plan 2018 Beca Group 1 ROC = rough order of cost 2 DHB = district health board 2019 THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS 3 Asset management source documents Author Title Date New Zealand Health and Disability review Interim report: Section 10: System enablers 2019 OAG3 District health boards’ response to asset management requirements since 2009 2016 OAG Reflections from our audits: Investment and asset management 2017 Audit New Zealand Asset management and long-term planning: Learning from audit findings 2015 to 2017 2017 Cabinet Office CO (19) 6: Investment management and asset performance in the state services 2019 OAG Managing public assets: Discussion paper 2013 King’s Fund Clicks and mortar: Technology and the NHS estate 2019 NSW4 Audit Office New South Wales Auditor-General’s Report: Performance audit: Medical equipment in NSW public hospitals 2017 The Center for Health Design A guide to clinic design post-occupancy evaluation toolkit 2015 Fronczek-Munter, A Evaluation methods for hospital facilities 2013 Victorian Government Medical equipment asset management framework 2012 Sizing up the challenge ahead: Future demographic trends and long-term care costs Investing in Hospitals of the Future Assets in action: An asset management guide for non-technical managers 2011 5 OECD WHO6 Rechel et al NHS7 estates 4 3 OAG = Office of the Auditor-General 4 NSW = New South Wales 5 OECD = Organisation for Economic Co-operation and Development 6 WHO = World Health Organisation 7 NHS = National Health Service THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS 2009 2003 Executive summary Context District health boards (DHBs) manage buildings with a replacement value of around $24 billion, and there is also considerable investment in clinical equipment and information technology (IT). Therefore, capital investment and other aspects of asset management make a significant call on financial resources. Further, the decisionmaking environment for capital investment and management is complicated by a mix of local, regional and national considerations. As noted in the Health and Disability System Review interim report (2019, p 263), ‘The current state of DHB assets is not good and there is little in the way of long-term planning which can give any confidence that the problem is under control.’ Resources have tended to be directed to managing short-term operational pressures, rather than to plan for and invest in longer-term sustainable solutions, including infrastructure. And it is not just a matter of remediating the accumulated investment deficit; we need to build the capability to support system transformation, especially as models-of-care evolve, including the advances in clinical equipment and technology that enable shorter hospital stays and more community-based care. In addition, a growing and ageing population will continue to see increased demand for both hospital and community services. Based on 2018 DHB capital estimates, $14 billion of investment is required for buildings and infrastructure over the next 10 years. In 2019, the Ministry of Health estimated a requirement for $2.3 billion for DHB IT8 over the same period. The development of a Health National Asset Management Programme (NAMP) is a key initiative to improve the planning and management of health assets. The NAMP process began in 2018–19 to establish a national long-term investment plan founded on a consistent nationwide approach to asset management. This current-state assessment report is the first deliverable, which will be followed by a full National Asset Management Plan with investment scenarios in 2022. The NAMP is part of a government-wide focus to improve the quality of capital funding decisions, asset management, and long-term investment outcomes, in which the primary objective is to deliver the best value from new and existing investments for generations of New Zealanders. The Government has set clear objectives to have asset management plans in place to guide strategic, tactical and operational choices under Cabinet Office circular CO (6) 2019. This circular specifies all aspects of the investment lifecycle for assets and applies to DHBs along with other government agencies. The NAMP is intended to guide strategic investment choices at a sector level, and it is 8 5 This estimate for IT was calculated from DHB operating expenditure during 2018/19, allowing for 2.2 percent additional funding per annum required to lift investment to the benchmark levels identified in the Deloitte (2015) independent review of New Zealand’s electronic health records strategy. expected that, over time, it will provide a consolidated picture of the DHBs’ asset management plans. What does this plan do? Work to date focuses on bringing together the current state into a national asset register. It provides a consistent picture of the condition, fitness-for-purpose, and deployment of critical assets, including buildings, infrastructure, clinical facilities and IT. In doing so, this initiative introduces consistent standards for the assessment of asset condition, functionality and consolidation of asset types. It provides a basis for moving towards national prioritisation of investment decisions that meet the Government’s wider budget and wellbeing priorities. The current-state assessment provides the framework to evolve into a national asset plan once asset levels-of-service are identified to inform investment scenarios. The NAMP has introduced the following enablers to strengthen health sector asset management capability: • the Health Asset Register Tool (HART), which is a repository for information on DHB-owned buildings, infrastructure, clinical facilities and the capacity of inpatient beds • a criticality matrix to determine the relative importance of hospital buildings for health services and compliance with the Building Act 2004 • guidelines for consistent condition assessments of hospital buildings and infrastructure that inform both professional assessments and DHB self-assessments • a methodology to determine the fitness-for-purpose of clinical facilities that strengthens understanding of the requirements for size, layout and accommodation of new health technologies • guidelines on seismic risk, and a method for assessment of structural resilience that is currently under pilot • indicative standard costs for refurbishment and replacement of facilities to allow consistent cost estimates in future investment plans • initial asset management awareness training that was well received and should be continued, alongside revitalisation of the Health Assessment Management Improvement group of health sector asset managers. This is a significant body of work that is a step-change for health sector asset management capability and long-term investment planning. It will be evolved through future assessments and the development of asset management and investment plans. DHBs have welcomed and embraced the guidelines to date and collaborated on all the assessments. Not all of the 2019/20 work completed is represented in this report. Other work on the assessment methods and guidelines contributes to the health sector asset management framework and provides a foundation for the asset management plan. The document list at the front of this report includes other reports and material that has been produced by the programme. 6 THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS This current-state assessment provides evidence to determine the relative investment priorities, which include: • sitewide infrastructure (eg, pipes and electrical power) • building operability (eg, passive fire separation) • mental health and intensive care units, including the fitness-for-purpose, condition and maintenance of facilities • core IT applications, including financial management, patient administration and pharmacy management systems. Public-facing facilities are generally in better condition than the infrastructure, facilities and systems where the condition is less immediately evident. What does this current-state assessment not (yet) do? The initial work in this current-state assessment lays the foundation for improving the quality of capital funding decisions, asset management and long-term capital investment to contribute to better outcomes across the health sector. Ongoing work is required to develop a framework for prioritising capital funding and understanding long-term investment requirements. A work programme is being developed, and a key checkpoint will be the future delivery of a formal National Asset Management Plan. We now have a consistent view of the major health facilities, which alongside the other investment management functions currently in development, will support a more robust national investment plan. The other drivers of investment planning to support the NAMP will be national service design and facility standards, settings, frameworks and guidance. As the programme and plan evolve, it will enable the health and construction sectors to develop their capacity and readiness with more certainty. A key principle of asset management is to develop targets that define the asset levelsof-service, which is necessary to ensure each asset meets the design and condition requirements to support the needs of health service delivery. An investment plan and, or scenarios will be developed to cost the ‘gap’ between the current and target asset levels-of-service. The work to date provides a good assessment of the current-state of assets, but targets for asset levels-of-service have not yet been identified. Scope of the review Table 1 sets out the scope of the assets included in the 2018–19 assessments. 7 Table 1: Scope of 2019 asset assessments Not included in this currentstate assessment Asset type In-scope 166 buildings Expert assessments: Condition of 166 buildings at main hospital campuses built pre-2000. Health-owned buildings not at main hospital and facility campus sites. 933 buildings Self-assessments: 933 of all other buildings. Leased property (that DHBs occupy but do not own). 80 clinical facilities 52 units = 50% of acute pathway units (emergency departments, operating theatre suites, intensive care units) and 19 inpatient units in pre-2000 buildings, along with 4 control units in newer buildings. Acute pathway units in post2000 buildings, most inpatient units and all other types of clinical facilities. • 56 acute pathway units • 23 units = 50% of mostly acute mental health 24 mental health units inpatient units in buildings pre-2009, 1 control unit in a newer building. Other 50% of mental health inpatient units, 100% of forensic mental health units. Infrastructure – All sitewide reticulated infrastructure (ie, 31 main plumbing, electrical, mechanical) except at campuses Dunedin and Whakatāne hospitals. Siteworks, roading, carparks, open spaces. Information technology Other core applications at DHBs. 5 core applications at each DHB. Northern region IT infrastructure, data centres, networks and security (healthAlliance and Northland, Waitematā, Auckland and Counties Manukau DHBs). Reticulated infrastructure at other locations. IT infrastructure, networks and security at the other DHBs. Clinical equipment Clinical equipment (will be included in future NAMP reports). Other minor assets All minor assets (according to criticality and materiality will be included in future reports). What did the work find? The results of the current-state assessment (the review) carried out as part of the NAMP are outlined below in respect of buildings and infrastructure, older clinical facilities, and IT. Several factors contributed to the results, including: 8 • health sector weakness in asset management • the prioritisation of expenditure on operational rather than capital requirements, which has led to a significant backlog of deferred maintenance • the demands of rapidly changing health technologies • the inability of DHBs to adapt quickly enough to changing demands. THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS Buildings and infrastructure Buildings are mostly in average to good condition, with those in average condition having various poor components. The review identified key operability issues, including risks levels for structural integrity, seismic restraints, passive fire separation and presence of asbestos. The average age of buildings at DHBs ranges from 28 years at Waitematā DHB to 53 years at Southern DHB. Generally, the older the building, the poorer its condition. This in turn affects the housing of clinical facilities and data centres. Sitewide infrastructure was in relatively poorer condition than the main campus buildings. Many campuses have significant issues with reticulated infrastructure, including electrical systems and pipes at or near end-of-life and not designed to support continually increasing operational loads. Many mental health facility buildings are in better condition than main clinical blocks due to their location in low-rise and simpler building types. However, the interiors of mental health facilities were in poorer condition, as identified in the CFFFP assessments. Older clinical facilities The review assessed the CFFFP of 75 older and 5 newer units across five clinical services nationwide. The units were mostly located in older hospital buildings, with many having well-known shortfalls compared to current guidelines. The divergence from current Australasian guidelines was used to identify the relative appropriateness of the clinical facilities to support their models-of-care. As design standards are established for the New Zealand health sector, new builds will be expected to meet these. The 2019 assessments produced the following results. • Mental health units: Over two-thirds of the older units have facility designs inadequate for the management of patient cohorts, demand pressures, poor maintenance and safety issues. • Inpatient units: Older units generally have poor facility designs and floor areas, and they are generally not reconfigurable. There are common issues of lack of storage, clutter causing safety concerns, infection control issues and a lack of spaces and ceiling-mounted hoists for bariatric care. • Intensive care units: Most older units do not meet current guidelines for physical space, configuration and storage. Some also have issues with infection control, patient observation, negative-pressure rooms, and with medical gas and suction services. • Operating theatres: Some older theatre suites are too small or have a mix of acceptable and undersized theatre rooms. This partly reflects the need to accommodate continuing advances in clinical and information technologies as the facilities age. • Emergency departments: Most older departments do not meet current guidelines. Issues include undersized bed bays, poor layout, and corridors cluttered with equipment. While most do seem to be managing the increased demand, having 9 appropriate spaces to manage people who require a mental health assessment is an issue. Information technology The review synthesized existing material to assess several core applications, along with the state of the digital health environment, data standards and IT infrastructure. There are significant issues with legacy systems and outdated infrastructure, which means that the benefits of health IT to enable health equity and lift health service productivity have not been realised. These assessments found the following: • Digital health environment: Audits found that IT strategy, governance, and asset management operate at a basic level. The presence of legacy systems, incompatible devices and outdated infrastructure has created ongoing challenges for users to access and use patient and clinical information across both internal hospital locations and wider health service settings. • Core applications: The sample included selected systems at all 20 DHBs. Assessments found 10 DHBs with poor financial management systems, four with poor or very poor patient administration systems, four with very poor pharmacy management systems, and one with a very poor clinical portal system. • National data standards: The slow progress with adoption of four key standards has limited the interoperability necessary to share, reuse and analyse information that would enhance both clinical and management operations. • IT infrastructure, networks and security: These are outdated and not adequate to support the introduction of new systems and to manage the increased cyber security issues. While digital health has become critical to the delivery of services, there are significant risks to services from a lack of system capacity, resilience and business continuity arrangements. Covid-19 pandemic While the NAMP 2019 assessments predated the Covid-19 pandemic, the assessment findings contribute to ongoing work on emergency preparedness. This report highlights several issues important for management of large numbers of people with infectious and life threatening illness. The Covid-19 response experience underlines the importance of the next phase of NAMP assessments. The capacity of sitewide electrical and medical gas capacity can limit the numbers of ventilators and monitoring equipment that can be operated at the same time. The clinical facility fitness-for-purpose (CFFFP) assessments identify issues with patient separation, clean and dirty workflows and suboptimal surfaces that creates difficulties around infection control. There are older negative pressure rooms, used to isolate infectious patients, that are poorly designed compared to the Australasian Health Facilities Guidelines (AHFG). The design issues include inadequate size, lack of anterooms, and problems with doors seals and ventilation. Health sector slowness to adopt standards that enable interoperability between health applications and support tracking of equipment and people is outlined in this report. 10 THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS The Covid-19 response has also highlighted issues with the procurement and availability of clinical equipment, particularly for intensive care. Better integrated IT and telehealth applications would expedite the provision of services to many people, without the need for a hospital visit. A robust assessment method is being developed for clinical equipment and IT as part of the next phase of the NAMP. Next steps The Ministry of Health’s Health Infrastructure Unit is working on a prioritised work programme to improve asset management in the health sector. This will be based on the improvement actions that have been identified in this report and are aligned to the available resources. The high priority next steps are as follows. • Deliver a National Asset Management Plan incorporating investment scenarios to Ministers in 2022. • Continue to work with DHBs to improve asset management practice and increase capability, including leveraging good practice identified in available asset management plans. • Develop national service design and facility standards, settings, frameworks and guidance for capital planning. • Develop asset levels-of-service aligned to national service design to quantify longterm investment scenarios. • Develop more extensive and detailed assessments for digital health maturity. • Develop scope, standards, priorities and complete assessments for clinical equipment. • Develop a sector-wide capital investment framework and plan. • Develop renewal and maintenance strategies. • Incorporate more emphasis on health equity and sustainability in asset management practice, including to reduce greenhouse gas emissions, and achieve carbon zero targets. 11 Section 1 Introduction This current-state assessment creates a consistent nationwide picture of the condition and fitness-for-purpose of district health board (DHB) buildings, infrastructure, clinical facilities and information technology (IT) assets. Alongside other prioritisation criteria, it will help inform capital investment decisions and provide a foundation for evidence-based asset management plans to enable effective health service delivery. In May 2018 the Minister of Health announced the Government’s intention to address the poor state of health infrastructure (Minister of Health 2018). At the time, there was uncertainty around the DHBs’ estimated need for a $14 billion investment over 10 years, and the dependence on Crown funding (Treasury 2017). As a first step, the Minister commissioned a national asset management plan to establish a consistent nationwide picture of the state of DHB assets and forecast the population demand for services over the medium to long-term. This first report of the National Asset Management Programme (NAMP) outlines the current state of the assets. DHBs operate with an accumulated under-investment in assets, and many believe their assets to be in poor condition and no longer fit-for-purpose. Work through 2018–19 indicates investments of $14 billion for buildings and infrastructure and $2.23 billion for IT are needed over the next 10 years. However, there are financial constraints, capacity issues for the construction sector and a requirement for a national evidencebased prioritisation framework. Further, there are competing demands on DHBs’ funds, with increased clinical complexity relating to an ageing population, and ongoing developments in health and digital technologies. The direction in the New Zealand Health Strategy is to leverage new technologies and models-of-care to deliver more services in outpatient and community settings, rather than in hospitals. At the same time the strategy anticipates that population ageing will increase the demand for health services, including hospital care (Minister of Health 2016). 12 THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS This report sets out the current-state for selected assets in DHBs. Section 1 provides background on the government-wide agenda to improve asset management. Next, it outlines the state of asset management and the context for capital investment decisions in the health sector. It concludes with the role of the NAMP in the sector and a readers’ guide for this report. Government-wide context The NAMP is part of a government-wide agenda to improve the quality of asset management and long-term investment plans. Other large agencies have been building their capability in asset management and investment, such as the New Zealand Defence Force, the NZ Transport Agency, the Ministry of Education, the Department of Corrections and Kāinga Ora. The Ministry of Health differs from most central government agencies because it funds but does not own the assets. DHBs own buildings and infrastructure with a replacement value of around $24 billion and a similar investment in fittings, clinical equipment and IT. This asset base is large, with a complex operating environment. Several agencies have oversight of health sector capital investment. DHBs must seek joint approval from the Minister of Health and the Minister of Finance for investments over $10 million and where Crown funding is required (National Health Board 2011). The Capital Investment Committee (CIC)9 provides independent advice to these Ministers. The Ministry of Health and The Treasury provide advice to their respective Ministers and support the deliberations of the CIC. There have also been initiatives to encourage improvement in asset management and long-term investment plans. The Office of the Auditor-General (OAG) provides government with independent assurance about the DHBs’ asset management and financial performance. The Treasury has used the investor confidence rating (ICR) to assess the quality of financial and asset management for capital-intensive agencies every three years (Cabinet Office 2015). The Health Asset Management Improvement group is a forum designed to encourage improvement and share knowledge in the health sector. Sustained attention to asset management and long-term investment plans is essential to build health sector capability. As outlined below, the journey to this first report began with the introduction of asset management plans for DHBs in 2009. The NAMP has evolved from the accumulated effort since then, with the second report and plan due in 2022. 2009 2011 2014-15 2015 2015 2016 2017 9 Introduction of asset management plans for DHBs CIC established and regional plans introduced The Treasury and Ministry of Health review asset management maturity Health Asset Management Improvement (HAMI) group established Investor confidence ratings introduced OAG reports that DHB asset management is immature Long-term investment plans introduced for DHBs The CIC is a committee established under legislation to advise the Ministers of Health and Finance. 13 2018 2018 2017–19 2018–19 2020 2020-21 2022 18 DHB long-term plans submitted to the Ministry of Health First long-term investment plan for the Northern Region produced Two rounds of ICR assessment for seven DHBs and Ministry of Health First NAMP assessments undertaken NAMP Report 1: Draft current-state assessment NAMP Phase 2 programme of work NAMP second report: National Asset Management Plan Health sector asset management Audits of DHBs found that poor asset management has compromised the quality of long-term plans (Office of the Auditor-General 2016). Internationally, poor asset information has been linked to suboptimal allocation of health sector capital (Marriot et al 2011). In 2020 the Covid-19 pandemic response also highlighted weaknesses in health sector asset management, notably around the capacity of facilities, sitewide infrastructure, clinical equipment and IT. In 2018, the NAMP and Morrison Low visited 11 health agencies to assess the quality of asset information. Included were healthAlliance and the Auckland, Waitematā, Counties Manukau, Tairāwhiti, Taranaki, Capital & Coast, Hutt Valley, Wairarapa, Nelson Marlborough and Canterbury DHBs. All agencies were willing to engage and share information for the benefit of the health sector. To provide detailed feedback for DHBs, Morrison Low constructed a 1–3 rating to indicate progress on 22 areas of asset management practice for buildings, infrastructure, IT and clinical equipment. Of the 11 agencies, 8 were assessed for IT asset maturity because healthAlliance manages IT assets on behalf of the Northern Region. Only the 10 DHBs were assessed for management of clinical equipment assets. Figure 1: shows: • least mature in red: asset levels-of-service; alignment of multiple asset and finance registers; consistency of data; and completion of asset management plans • improving in orange: asset registers and condition and performance assessments for infrastructure, buildings and IT • most mature in green: condition and performance assessments for clinical equipment. This is a less detailed assessment than completed for the ICR. Conducted by The Treasury, the ICR takes a more in-depth look at the performance of individual agencies in the management of their investments and assets. It provides an indication of the level of confidence that investors (such as Cabinet and Ministers) have in an agency’s ability to realise a promised investment result if funding were committed. Seven DHBs and the Ministry of Health have been assessed through two rounds of the ICR, which includes scoring of their asset management maturity and asset performance. The results of the ICR are on The Treasury’s website: https://treasury.govt.nz/information-and-services/state-sector-leadership/investmentmanagement/review-investment-reviews/investor-confidence-rating-icr/resultsinvestor-confidence-rating-icr 14 THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS The ICR process has encouraged Waitematā, Auckland, Counties Manukau, Waikato, Capital & Coast, and Canterbury DHBs to develop asset management plans, although there was no national framework to enable a consistent nationwide picture. The NAMP has been established to achieve this. Figure 1: Asset management maturity assessed by Morrison Low in 2018 Mature Number of agencies 0 Improving 2 Immature 4 6 8 10 12 The capital investment process Under the current process of capital investment allocation, DHBs develop business cases to bid for a share of the annual capital available. The information used for decisions comes from stakeholders operating at different levels of the health sector. At the highest level, capital budgets are set as part of a whole-of-government budget process. For DHBs, business cases are variously constructed from a range of information about population need, asset condition and service enablers like modelsof-care, workforce, information and clinical technologies. These business cases are often developed in isolation from DHB neighbours and regional partners. An exception is the long-term investment plan developed in 2016 by the four northern DHBs, which are developing a 10-year roadmap for capital investment. Overall, there is limited consistency and transparency of information at either the local, regional or national levels. 15 The immaturity of health sector investment and asset management means that asset management plans have not informed the business case process. This has increased the effort and time for DHBs to develop each business case. It has also lengthened the process of business case review as further information and clarification has been necessary to establish a level playing field in the decision-making processes of capital allocation. In addition to the issues around information quality, capital investment decisions in the health sector are complex. While buildings can have a life of 30–50 years, the designs for effective health facilities change more rapidly. Government and DHBs face a mix of competing considerations for capital investment decisions, including: • changes to demographics, affecting the types and quantity of services required • delivery of equitable health outcomes across regions and populations • current government priorities such as outcomes for mental health and Māori • the condition of buildings and infrastructure, and the optimal time for renewal • shifts of health services from hospital to community settings • optimal leverage of health and information technologies, workforce and models-ofcare • improved availability and access to services for consumers • synergy with regional and local initiatives and stakeholders • value-for-money and service sustainability • advances in technology and innovation that support environmental sustainability. In this environment it is essential to consider changes in facilities design, health sciences, models-of-care, IT and clinical equipment, rather than replace assets like-forlike. An optimal investment could be to build an ambulatory care centre located to facilitate access for vulnerable populations or co-located with primary care teams rather than within a hospital. A mature asset management approach focuses on the services required and ensures that non-asset solutions are included in decisionmaking. Why have a NAMP? The NAMP is an important part of the Ministry of Health’s stewardship of the health system. It will inform the capital investment plans to enable effective service delivery and improve health outcomes. For the wider economy, the 2020 current-state assessment and the plan due in 2022 will encourage the construction sector to understand the long-term capital pipeline and develop and retain a skilled workforce (Minister for Building and Construction 2018). For the health sector, the NAMP will: • 16 provide leadership and expertise to improve the maturity of DHB asset management THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS • inform national and regional investment plans by supplying a consistent currentstate picture of the condition, lifecycle and capacity of the health estate, along with the forecast demand for services • provide a transparent source of information to underpin robust discussion around capital allocation among DHBs, the Ministry of Health, The Treasury, the CIC and other stakeholders • form an important part of the Ministry’s work to improve long-term plans, including the development of guidelines on asset assessment, service plans, facilities standards, models-of-care and sustainability. The NAMP will influence a shift to strategic and lifecycle considerations in the management of capital investments. Research shows that moving too quickly through the conceptual and planning phases for new health facilities risks poorer long-term outcomes. The costs prior to occupancy are likely to account for only 6 percent of the lifetime costs of the building. Best practice is to maintain focus on health service strategy, the facility’s fitness-for-purpose and its operational cost, prior to occupancy (Bjorberg and Verweij 2009). What is the NAMP? Begun in 2018, the NAMP is a high-level strategic programme. Over time it will create investment pipelines to inform capital allocation, allowing for different scenarios for government investment. This includes funding from DHB budgets and additional capital allocations. The NAMP will provide guidelines to consistently identify and assess assets across DHBs. This includes the assets’ condition, expected life and cost of renewal. Information on the population demand, along with the assets’ level of service and expected life, will be used to plan the timing of large investments. This will form the basis for consideration of what types of assets and technologies should be deployed to replace those that are approaching end-of-life. In 2018–19, to establish the inaugural assessments, the programme delivered: • a framework to determine building criticality in health services • professional onsite inspection of 166 selected older and critical hospital buildings • self-assessments by DHBs of 993 other buildings • professional onsite assessments of infrastructure on 31 campuses • professional onsite clinical facilities fitness-for-purpose (CFFFP) assessments of 75 clinical units and 5 control units • Ministry of Health DHB digital systems landscape survey of core applications in DHBs • self-assessments by DHBs of the condition of their top 20 critical IT assets • assessment of asset management maturity in DHBs • a national electronic asset register • next steps for development of the programme. 17 The current-state assessment in this report uses data at an aggregated level to understand the condition and performance of assets in the health sector. These assets include buildings and infrastructure, clinical facilities and IT. (Clinical equipment will also be included in the 2022 report). Figure 2: shows how data is consistently assessed from components to assets, asset types and groups to support plans for maintenance, renewal and refurbishment and strategic asset management. Figure 2: Aggregation of asset information through planning levels In 2019 the Ministry of Health commissioned the development of an asset management repository, the Health Asset Register Tool (HART). So far, this repository has been populated with the 2019 assessments of building and infrastructure, bed capacity and CFFFP. Development of this asset register is ongoing, with plans to support wider stakeholder access in 2020. Figure 3 shows how the NAMP will work interactively with DHBs, both bottom up and top down, to improve the information flows that inform investment plans, priorities and decisions. 18 • The blue boxes show the role of the Ministry of Health’s Health Infrastructure Unit to provide guidance on services plans, facilities standards, demand and capacity modelling, models-of-care and sustainability. • In yellow is the lifecycle of asset management through acquisition, operation, maintenance and disposal, and the plans and business cases produced by DHBs. • The green box shows how the NAMP and DHB asset management link to strategic plans, business cases and the national framework for investment prioritisation supported by the Ministry of Health and The Treasury, for the CIC and the Ministers of Health and Finance. THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS Figure 3: NAMP, asset management and investment decisions Reading this report Section 1 looked at the health sector asset management and capital investment context, addressed the questions of what the NAMP is and why it is important, and outlined how it will operate in the future to inform health sector asset management. Section 2 sets out the approach and findings for assessments of 1159 buildings and the sitewide infrastructure on 31 campuses. The building estate is in a mostly average to good condition, as DHBs have endeavoured to maintain assets despite a short-term planning focus. There are elements of older buildings, building operability and sitewide infrastructure in poor condition. Section 3 sets out the approach and findings for the CFFFP of 75 units in older buildings, along with five comparison units in newer buildings. This was around half of the emergency departments, operating theatre suites, intensive care units and mental health inpatient units nationwide, along with a sample of 20 older inpatient units. As expected, the older units scored from very poor to average, with a poorer range of scores for mental health and intensive care units. These assessments will inform conversations around improvement with DHBs. Section 4 sets out the approach and findings for the assessments of IT assets. This included DHBs’ core applications, the complex and fragmented digital IT environment, the slow progress with adoption of national data standards, and poor condition of infrastructure. While DHBs have maintained their IT assets, IT governance and asset management is basic. Significant investment is required to address issues with legacy systems and ageing infrastructure, and to invest in technologies that enable health services to transform to new models-of-care and increase community-based delivery. Section 5 sets out next steps for the NAMP through 2020/21, and the second report targeted for 2022. 19 Section 2 Buildings and infrastructure Robust investment plans are required to address poor components and shift the overall condition scores from poor or average to good. While DHB buildings are mostly in an average to good condition, the average scores indicate poor components. Also, in many cases the building operability and sitewide infrastructure are in poor condition. Most buildings assessed were in average to good condition. DHBs have made best efforts to maintain their assets in the current environment of short-term planning. The buildings have an average age of 28–50 years, which indicates they are approaching end-of-life and are likely to have poor components within their average condition scores. For the 31 campuses assessed, scores for mechanical infrastructure were 9 poor, 21 average, and 1 good. For electrical infrastructure10 scores were 1 poor, 13 average, 14 good and 2 very good. Further work is needed, to understand the asset levels-ofservice for the buildings and infrastructure to compare these to the current state assessments. This comparison will show whether these assets appropriately support the respective health services. Under the 2017 changes to the building regulations, there are now 52 buildings at importance levels 3 and 4 considered earthquake prone. A significant number of these buildings are currently being redeveloped at the Dunedin, Taranaki Base and Grey Base hospitals. The 2017 regulations require that remediation work be completed by 2027 for regions with high seismic risk and 2034 for regions with medium risk, although territorial authorities may grant time extensions. There are also opportunities identified by DHBs and the Ministry of Health for investments to improve the components of building operability that protect occupants through disasters. These include the quality of seismic restraints, passive fire separation and continued work on the management of asbestos. 10 20 There are electrical infrastructure scores for 30 of the 31 sites. At the time of the inspection, there was no access to assess the electrical infrastructure at Point Chevalier. THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS This section begins with the assessment approach used by the NAMP and DHBs for this current-state analysis. Next, it reports on the mean age and condition of buildings, and their seismic integrity, followed by the buildings’ operability including seismic restraints, passive fire separation and the presence of asbestos. The section then reports the condition of sitewide infrastructure on 31 campuses and concludes with schedules of cost estimates for new builds and refurbishments of different types of DHB buildings. Further information is set out in Appendix 4. Assessment approach A criticality matrix was developed with DHBs to select 166 buildings and 31 campuses for professional assessments by the NAMP team and Beca Group. DHBs self-assessed the remaining 993 buildings using the assessment guideline and an electronic survey tool. Consistent methods were used to create a nationwide picture of the health estate. This included identification of key asset components and measures for grading condition. There is consistency between the professional and DHB self-assessments except that the professional data is more detailed. This ensured the task was achievable for the DHBs. Scores were reviewed with each DHB, and only adjusted where evidence supported this. When making decisions on the future of critical buildings, knowledge of each building’s ability to be operational after an earthquake is required. The NAMP, Beca Group and Kestral developed guidelines for DHBs to procure seismic assessments, along with a method to produce a standardised seismic rating to support comparison of the buildings. This method was applied to assess the seismic resilience of 34 properties. Table 2 shows the components assessed for building condition, seismic integrity and building operability. Table 2: Assessment components for buildings Buildings For buildings, information was collected on the condition, condition variability and estimated time to replacement for: • building fabric (external and internal) • mechanical, heating, ventilation, air-conditioning and plumbing • electrical, power, lighting, extra-low voltage, lifts, fire systems. Seismic integrity For seismic integrity assessments are based on: • structural integrity: earthquake safety as a percentage of the new building standard (%NBS) from existing initial and detailed seismic assessments • 21 seismic resilience: a pilot study to identify seismic resilience where possible was calculated from detailed seismic assessments Building operability Building operability components affect the safety of the building for its occupants day-to-day and through disasters. Risk was assessed as low, medium and high for: • asbestos, passive fire separation and seismic restraints. Scores for building operability, including passive fire separation, likelihood of asbestos and quality of seismic restraints, are: High risk Medium risk Low risk Table 3 shows the components assessed for the sitewide infrastructure that connects services to buildings. These assessments excluded the components assessed for buildings. Table 3: Assessment components for sitewide infrastructure Sitewide electrical infrastructure • Substations • Site distribution mains Main switchboards Site generators (backup power supply) • • Sitewide mechanical infrastructure • • • • • • Steam pipes Heating pipes Heating plant Cooling pipes Cooling plant Medical gases • • • • • Storm water drains Cold water supply pipes Hot and cold water site pipes Hot and cold water storage Sewer drains Analysis This current-state analysis is a nationwide picture of the condition of buildings and infrastructure, structural integrity and building operability. In this report, the graphs show mean (average) condition scores across critical and non-critical buildings, regardless of their age. The following factors in this assessment contribute to better mean condition ratings. • • • • 22 Compared to the professional assessors, the DHBs tend to assign lower scores that indicate better condition to the 993 buildings they assessed. The building portfolio includes newer as well as older buildings. Averaging obscures the poor-scoring outliers that are mostly older buildings. An average score for a building contains many components. A building with an average score of 3.0 can comprise good and poor components, while any building that scores higher than 3.0 has components with significant issues. When all the critical and non-critical buildings are included, a more even distribution score is produced. There is more variation in scores for analysis at the building component level. THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS Table 4 sets out definitions for the condition scores used for fabric, electrical and mechanical components of buildings and the components of sitewide infrastructure. Table 4: Condition score definitions for building and infrastructure Rating Condition Definition 1 Very good Assets displaying no deterioration or only normal routine maintenance required. New or near-new condition or repaired as good as new. 2 Good Assets displaying limited deterioration that does not affect their use or where limited restoration has been performed. Minor maintenance may be required. 3 Average Assets that have deteriorated to a degree where maintenance is obviously due, but not to the extent that the function is significantly impaired. 4 Poor Assets that need repair or renewal in the short term because their condition is severely impacting performance. Barely serviceable, and failure likely in the short term. 5 Very poor Immediate repair or renewal required. Assets have failed or failure is imminent. May pose health and safety issues and requires urgent attention. Mean age and condition of buildings Figure 4: shows the mean age of the buildings at main campuses ranges from 28 years at Waitematā DHB to 53 years at Southern DHB. Generally, the older the building, the poorer its condition, and suboptimal maintenance reduces the useful life of the building. For clinical buildings, refurbishments can be expected after 25 years and major refurbishment or renewal after 50 years. The vertical lines show the age range for buildings in each DHB. 23 Figure 4: Mean age of major campus buildings for all 20 DHBs 2040 2020 Year Built 2000 1980 1960 1940 1920 1900 1880 Figure 5: shows the mean condition scores for all DHB buildings, calculated on a gross floor area. There are 10 with good and 10 with average scores.11 No DHBs had poor or very poor scores. However, the average scores indicate the presence of some components in poor condition. Figure 5: Mean building condition scores weighted for gross floor area Condition Score 5 Very poor Poor Average Good Very good 4 3 2 1 0 Figure 6: shows a wide distribution of mean condition scores for buildings accommodating mental health inpatient units. There are 2 very good, 7 good, 9 average and 1 poor. Many buildings had been refurbished and repurposed to accommodate mental health units. However, as the poorer scores for CFFFP indicate, many repurposed buildings did not have floor plans appropriate for mental health services, which can compromise service delivery. The buildings are mostly low-rise with fewer mechanical components, and therefore easier to maintain. However, in many cases the interiors were found to be in poorer condition compared to the mean condition score for all the buildings. The two with very good building condition scores are newer facilities. 11 24 West Coast DHB was not included due the current hospital rebuild. THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS Figure 6: Mean condition scores for buildings that house mental health units Operability of buildings Buildings were assessed for operability, which relates to their capacity to be safe for patients, staff and visitors. Assessments included structural integrity, seismic restraints, the presence and condition of asbestos, and the passive fire separation. Structural integrity and resilience In 2019, the Ministry of Health requested that DHBs provide the NAMP with all their %NBS scores for buildings where a seismic assessment has been completed. Previously, DHBs supplied their %NBS scores only for earthquake-prone buildings. This work is currently in progress, with 60 percent of buildings having the %NBS recorded. Scores are not required for non-essential buildings such as garages and sheds. The building regulations related to earthquakes were changed substantially in 2017, which has had a significant impact in the health sector with its large proportion of importance level 4 and 3 (IL4 and IL3) buildings. The regulations identify buildings with emergency departments and operating theatre suites as IL4, and these buildings are likely to house other critical hospital services. The %NBS requirements are higher for buildings with a higher importance level; for instance, IL4 compared to IL3. Improvements are required for buildings that are identified as less than 33% NBS which are classified as earthquake prone buildings. This includes buildings scored as a D or E in the scoring below for any importance level. The timeframe for improvements depends on the seismic risk, being 2027 for areas with high risk and 2034 for areas with medium risk. Figure 7: shows the completed structural integrity information for 1229 buildings. It shows the numbers of buildings, the importance level of 1 to 4; and for each importance level the proportion of buildings with a score A+ to E that equates to a %NBS range. The %NBS scores indicate that there are 52 buildings (30 IL4 and 22 IL3) with scores of D and E, which are earthquake prone according to the new building regulations. All affected DHBs have plans to address these requirements. Among these 52 buildings 25 are those at the Dunedin, Taranaki Base and Grey Base hospitals currently being redeveloped. The Ministry of Health will be working with DHBs to determine the most appropriate action in relation to the small number of other buildings. The IL3–4 buildings where there is presently no %NBS data are mostly located in areas of low seismic risk. While the Ministry is encouraging DHBs to assess all IL4 buildings, the building regulations allow up to 35 years for this in areas of low seismic risk. Figure 7: Importance level of buildings and degree of earthquake risk (%NBS) A+ >100% NBS B 67–79% NBS D 20–33% NBS A 80–100% NBS C 34–66% NBS E <20% NBS IL4 - Graded NBS Scores and Number of Buildings Not assessed IL3 - Graded NBS Scores and Number of Buildings 10 12 57 87 60 10 9 20 63 40 13 35 32 77 IL2 - Graded NBS Scores and Number of Buildings IL1 - Graded NBS Scores and Number of Buildings 2 36 6 87 1 1 41 317 127 35 16 35 The structural integrity measured as %NBS relates to the building’s ability to protect the life of its occupants through a disaster. The Ministry of Health will work with DHBs to determine asset levels-of-service that are likely to include seismic resilience. Seismic resilience is a different concept from %NBS. It rates a building for its capacity to provide service continuity following a disaster. A method that uses DHBs’ seismic assessments to assess their buildings seismic resilience has been developed and is being piloted. 26 THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS Seismic restraints Most seismic restraints complied with the standards required at the time the building was constructed. In some cases, there have been upgrades to retrofit modern seismic restraints to older buildings. Overall the quality of the restraints varies, from robust frames to secure heavy equipment such as water storage units, to similar units poorly secured with limited restraint. These issues were identified through the joint DHB and NAMP assessments, and the Ministry of Health will seek plans to improve seismic restraints. Figure 8: shows the risk levels of seismic restraints as a proportion of buildings, with 39 percent low risk, 20 percent medium risk, 10 percent high risk and 31 percent not yet assessed. Figure 8: Risk levels of seismic restraints as a proportion of buildings Low risk 372 31% 117 10% 465 39% Medium risk High risk Not Assessed 230 20% Presence of asbestos Many DHBs are managing significant levels of asbestos present in buildings, including maintenance of an asbestos exposure register and reports to WorkSafe New Zealand. There are special procedures in place to protect building occupants, and the most significant issues relate to the friable asbestos lagging of pipes. In cases where there were significant issues, the previous and planned work to remove asbestos was discussed with the DHB. Asbestos is generally managed through isolation and encapsulation, with removal where necessary. Removal can be difficult where pipes are in constrained areas or pass through walls. Moderate asbestos is usually encapsulated. Figure 9 shows the risk levels for presence of asbestos as a proportion of the buildings, with 39 percent low risk, 20 percent medium risk, 10 percent high risk, and 31 percent not yet assessed. 27 Figure 9: Risk levels for presence of asbestos as a proportion of buildings Low risk 372 31% 117 10% 465 39% Medium risk High risk Not Assessed 230 20% Passive fire separation Active fire protection systems include alarms and sprinkler systems that are subject to regular building warrant-of-fitness procedures with local government, so were not included as a specific assessment in this report. Passive fire separation is usually evaluated against the standards in place at the time of the building’s construction. This assessment focuses on the current issues, rather than performance against previous standards. In many cases, passive fire separation has been compromised by poor practices around the installation of new technologies, such as cabling. DHBs have advised the Ministry of Health that controls are now in place to ensure that fire cells are not compromised by new IT installations. There have been problems with holes drilled through walls to feed cables that were left unsealed or sealed with nonfire-resistant sealants. Unsealed holes enable smoke and flames to spread through buildings, compromising passive fire separation. In many cases, DHBs have remediation programmes that are expensive and time consuming already in progress. Figure 10: shows the risk levels for passive fire separation as a proportion of the buildings, with 52 percent low risk, 16 percent medium risk, 11 percent high risk, and 21 percent not yet assessed. 28 THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS Figure 10: Levels of risk for passive fire separation as a proportion of buildings 249 21% Low risk Medium risk 616 52% 126 11% High risk Not Assessed 182 16% Combined condition and operability Older buildings generally have accumulated issues at the component level, poor %NBS scores, and may have operability issues. Tables 5 and 6 show extracts from the HART tool. From the left, is the building name, gross floor area, year built, mean condition score, building component score, seismic integrity and building operability. The building components include fabric, electrical and mechanical. The seismic integrity includes the graded NBS score and importance level. The building operability includes risks for passive fire separation, presence of asbestos, and seismic restraints. Table 5 also shows the number of facilities in the building that were assessed for clinicalfitness-for-purpose (CFFFP), and the mean score achieved on the nine CFFFP design principles. Table 5 shows all buildings housing clinical services that have poor condition scores. For this group of 24 buildings: • construction dates range from 1946 to 2011, with many built in the 1970s and three that have previously been refurbished • 62 percent of the building components were poor • graded NBS scores range from a good A+ score to a very poor E score • 11 had CFFFP assessments on some facilities with scores from average to very poor. The buildings house a range of services, including for the acute care pathway, clinical support departments, outpatients, child services, mental health and aged care. Some of the larger buildings such as at Grey Base Hospital are currently being redeveloped. 29 Table 5: The 24 buildings housing clinical facilities with poor condition scores Building name Year built Gross floor area (m2) Mean condition score Building component scores Fabric Mechanical Clinical facilities fitness of purpose Graded NBS scores Importance level Mean CFFFP score Number of facilities assessed for CFFFP 3.6 1 NMDHB Nelson George Manson 1960 6,863 3.7 3.6 3.5 4 C IL4 WtDHB Waitakere Special Care Baby Unit 1964 3,899 3.6 4 3.8 2.8 C IL2 CDHB Ashburton Laboratory and Pharmacy 1990 752 3.4 3.5 3.7 3 A IL3 CMDHB Ōtara Tāmaki Oranga 1970 509 3.4 3.2 3.5 3.5 B IL3 3.3 1 CMDHB Ōtara Spinal Unit 1974 5,632 3.3 3.4 3.5 3 C IL3 4.6 1 HBDHB Hastings Laboratory 1983 891 3.3 3.6 2.1 3.5 C IL4 1955/2012 5,623 3.3 3.4 2.6 3.5 A IL3 4.1 1 2000 1,465 3.3 3.3 3 3.4 B IL3 1972/1999 Wards 6A and 11) 8,437 3.3 3.4 1.9 3.9 A+ IL3 3.2 1 0 3.3 3.7 2.9 2.9 C IL4 2.3 1 SDHB Wakari Helensburgh WtDHB Mason Rata WtDHB North Shore Geriatric WCDHB Buller Medical 30 Electrical Seismic integrity ADHB Point Chevalier Buchanan 1973 2,294 3.2 3.1 3 3.4 B IL2 CDHB Christchurch Riverside 1980 17,722 3.2 3.2 2.5 3.7 D IL3 THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS Building name Year built Gross floor area (m2) Mean condition score Building component scores Fabric Electrical Seismic integrity Mechanical Graded NBS scores Importance level Clinical facilities fitness of purpose Mean CFFFP score Number of facilities assessed for CFFFP NDHB Whāngārei Child Health 1986 173 3.2 3.6 2.5 2.9 NA IL2 SCDHB Timaru Clinical Services East 1976 10,151 3.2 3 2.6 3.8 NA IL4 4 1 SCDHB Timaru Clinical Services Main 1976 3.2 2.9 2.5 4 C IL4 3.7 2 SDHB Dunedin Child Pavilion 1945 4,482 3.2 3.1 3.2 3.4 B IL3 TarDHB Clinical Services 1968 7,510 3.2 2.9 3.8 3.2 E IL4 3.8 1 15,000 3.2 3.2 2.5 3.5 2.3 1 4 2 WCDHB Grey Main CDHB Ashburton Radiology and Patient Records 1990 693 3.1 3.2 3 3 A IL3 CDHB Hillmorton Forensic Mental Health 1999 2,888 3.1 3.4 2.7 3 NA IL4 CCDHB Wellington Grace Neill 1980 17,630 3.1 2.9 3.2 3.3 A IL3 NDHB Whāngārei Surgical 1956 3.1 3.1 2.8 3.3 NA IL3 NDHB Whāngārei Te Roopu Kimiora 1977 0 3.1 3.5 3.2 2.5 NA IL2 NMDHB Wairau Main 2011 3,555 3.1 3 3.2 3.2 NA IL4 31 Table 6 shows the eight buildings with the worst mean condition scores. This includes six buildings that house support functions such as plant rooms, workshops and kitchens, and two buildings that house clinical services located at Nelson Marlborough DHB and Waitematā DHB. The results show: • almost all components were poor • 2 are classified as earthquake prone with a score of D, 4 were average with a score of C, and for 2 the scores were not applicable. • operability scores varied • date of construction ranges from 189112 to 1972. Table 6: 10 buildings with the poorest condition scores DHB Building name Gross floor area (m2) Mean overall condition score Building component scores Building operability Seismic integrity Fabric Electrical Mechanical Graded NBS scores Importance level Fire separation issues Likelihood of asbestos Seismic restraint issues ADHB GLane B5 1906 1,462 4 4 4 4 D IL2 high high high ADHB GLane B6 Costley 1891 1,404 4 4 4 4 D IL2 high high high NM Tapawera House 1962 57 3.9 4 3.5 NA IL2 low low low WtDHB Waitakere Woodford Hse 1972 2,023 3.9 4 3.5 3.9 C IL2 NA NA NA NMDHB Wairau workshop 1950 165 3.8 3.6 4 4 NA IL2 low high medium NMDHB Nelson George Manson 1960 6,863 3.7 3.6 3.5 4 C IL4 high high high HVDHB Kitchen 1942 3,233 3.6 4 2.8 3.4 C IL2 medium medium medium WtDHB Waitakere SNBU 1964 3,899 3.6 4 3.8 2.8 C IL2 Medium high high 12 32 Year built Costley Home, a New Zealand heritage-listed building. THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS Sitewide infrastructure Sitewide infrastructure is critical for the continuity of hospital services. Plans for this infrastructure must include support for future campus development. Significant issues were found in the professional assessments of sitewide infrastructure on 31 main hospital campuses. This includes electrical systems and pipes at or near end-of-life. The assessors noted that these issues can be overlooked in plans for the replacement and refurbishment of hospital buildings and are not visible to the public. In general, DHBs have maintained their sitewide infrastructure to supply medical gases, water, sewer pipes and electricity. However, electrical infrastructure upgrades are difficult to manage because hospitals are continuously operational. Assessors noted some suboptimal partial upgrades due to problems taking the electricity supply offline. Other difficulties relate to the lack of skilled people and replacement parts for repair of old infrastructure to a good standard, such as Pyrotenax cabling. There are also cases where DHBs have constructed new buildings on infrastructure that was nearing its end-of-life. Many of the boilers were old, of suboptimal design, or converted from oil to gas with low efficiency. Coal-fired boilers should be phased out to reduce CO2 emissions. There are more effective options to replace reticulated steam that operate at point-of-use. Many chilling systems are old, use refrigerants no longer in production and are harmful to the ozone layer. These systems should be replaced, and the old refrigerants safely disposed of. Some pipework is at the end of its economic life, with many valves that need to be replaced. A programme of certification could be used to minimise health service disruption from these faults. Several sites reported issues with pinholes in copper water pipes that relate to low-grade copper and changes to water treatment practices. Figures 11 and 12 show the mean scores for the professional assessments of DHB sitewide infrastructure, including 30 campuses for electrical and 31 for campuses for mechanical. The graphs cover sitewide components like pipes and cabling that connect services to buildings. The mechanical and electrical components within buildings formed part of the building condition assessments. Campuses vary in their complexity, for example mental health facilities do not require medical gases to be piped sitewide. Figure 11: shows the mean condition scores for sitewide electrical infrastructure at 30 campuses, with 1 poor, 13 average, 14 good and 2 very good. 33 Figure 11: Mean condition for sitewide electrical infrastructure at 30 campuses Very poor Poor Average Good Very good 5 Average Condition Score 4 3 2 1 0 Figure 12: shows the mean condition scores for mechanical sitewide infrastructure at 31 campuses, with 9 poor, 21 average and 1 good. Figure 12: Mean condition for sitewide mechanical infrastructure at 31 campuses Very poor Poor Average Good Very good Average Condition Score 5 4 3 2 1 0 The poorest mean scores for both electrical and mechanical sitewide infrastructure are at Palmerston North Hospital, Wellington Regional Hospital and Hillmorton Hospital. More details of specific issues are identified by campus in Appendix 4. Cost estimates Quantity surveyors Rider Levett Bucknall developed cost estimates per square metre (m2) for replacement and refurbishment of different building types, to support analysis of future investment. This provides an indication of like-for-like replacement or refurbishment and will support consistent cost estimates for investment scenarios. 34 THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS More detailed estimates will be required at the business case and project stages. Tables 7 and 8 set out these cost estimates. Included in these estimates were: • construction costs • an allowance for siteworks and landscaping (new build) • an allowance for infrastructure (new build) • design and construction contingency • professional fees • furniture, fittings and equipment • future escalation in costs during design • project contingency. Excluded in these estimates were: • demolition of existing structures • remediation of contaminated ground • ground improvement • land costs • development contributions • specific flood remediation requirements • sitewide infrastructure • IT requirements beyond those included in construction costs • future cost escalation for commencement beyond 2019 • DHB internal project and direct management costs • car park structure and GST. Refurbishment costs are for building interiors only and exclude resolution of existing compliance issues. The costings in Tables 7 and 8 assume a hypothetical completion date that ranges from 2021 to 2028. 35 Table 7: Health facility new build cost estimates Building type Cost estimates per m2 Tertiary hospital $13,250 Secondary hospital $10,000 Community hospital $7,500 Administration B grade $5,500 Industrial $2,000 Mental health $10,000 Forensic mental health $12,000 Table 8: Health facility refurbishment cost estimates 36 Building type & extent of refurbishment Cost estimates per m2 High technical extensive $8,500 Medium technical extensive $6,000 Low technical extensive $4,000 High technical moderate $6,000 Medium technical moderate $4,000 Low technical moderate $2,500 High technical minimal $750 Medium technical minimal $500 Low technical minimal $500 THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS Section 3 Clinical facilities’ fitness-for-purpose Seventy-five clinical units in older buildings were assessed for CFFFP across five services. Many units were undersized and achieved poor scores against the nine design principles, particularly among the mental health and intensive care units. The assessments looked at how well clinical facilities in older buildings perform compared to the design guidelines for new facilities. Over the last 25 years, guidelines for the sizes of rooms, layout and available therapeutic spaces have changed. Older units were not expected to meet the current guidelines. However, the findings about their ‘relative’ performance can inform conversations with DHBs about improvement strategies, and the national priorities for investment plans. The Australasian Health Facility Guidelines (AHFG) are used to inform the design of health facilities in New Zealand. The Ministry of Health’s new Health Infrastructure Unit will develop additional guidance for the design of new buildings and renewal of older facilities in the New Zealand environment. The assessments included five clinical services in older facilities: around half of the acute mental health units, emergency departments, operating theatre suites and intensive care units nationwide, and a small sample of the oldest inpatient units at 13 DHBs. Each assessment included the unit’s layout, size, physical aspects and use of space, and also considered how well it supports the model-of-care. For each of the five services, a unit located in a newer building was also assessed. The five newer units were expected to achieve better CFFFP scores. Further work with DHBs is required, to consider options to improve seven mental health units, three emergency departments, five operating theatres suites, five intensive care units and eight inpatient wards. Options could include a combination of changes to models-of-care, strengthening other services in the workflow, unit refurbishment and renewals. 37 This section begins with the approach for assessment. It then outlines the findings for mental health units, emergency departments, operating theatres, intensive care units and inpatient units. Assessment approach The CFFFP survey was developed in 2019 to assess New Zealand hospital units for how well they support their model-of-care and align with the Australasian Health Facility Guidelines. Assessments considered unit performance against nine clinical design principles: 1. 2. 3. 4. 5. 6. 7. 8. 9. Proximity of the unit to external clinical and clinical support services Appropriate co-location of key functions and activities in the unit Ease of access within the unit Adequate size and layout of key patient spaces Layout of space to facilitate staff communication and patient observation Support of audio and visual privacy Management of infection control Reduction in medication errors Physical security A further aspect of the units’ fitness-for-purpose is their size. The AHFG was used to develop a benchmark size for each type of clinical unit. Guidelines have changed over time. Therefore, older units were expected to have poorer scores when compared with these benchmarks. Table 9 shows that the assessment included around 50 percent of the acute mental health units, intensive care units, operating theatre suites and emergency departments nationwide. A typical inpatient unit was selected from an older ward block at 13 DHBs. Forensic mental health units were excluded from these 2019 assessments due to complexities with access. For each service, a control unit in a newer building was selected for comparison. Table 9: The 80 units assessed for CFFFP Type of unit Number Sample size Number of DHBs Acute mental health 24 Around 50% nationwide 17 Inpatient units 20 Small 13 Intensive care units 10 Around 50% nationwide 10 General operating theatre suites 15 Around 50% nationwide 13 Emergency departments 11 Around 50% nationwide 11 Assessments were piloted at the Nelson Marlborough and Hawke’s Bay DHBs, then implemented at the remaining 17 DHBs.13 In each case, assessments were completed in collaboration with charge nurses and key clinical staff. 13 38 Wairarapa DHB did not meet the criteria for inclusion because all its clinical facilities are in newer buildings. THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS For each unit, the analysis includes a total score on the nine clinical design principles, performance on gross floor area, a summary of the themes identified in the survey observations. Table 10 sets out the definitions for the mean scores on the nine design principles. An average score indicates poor performance on some design principles. Poor and very poor scores merit investigation and remediation. Table 10: Rating definitions for CFFFP assessments Rating Fitness-forpurpose Definition 1 Very Good Number, size, layout of key clinical and clinical support spaces, and overall configuration of department or unit is appropriate for model-of-care. Clinical department or unit displaying no deterioration or only normal routine maintenance required. New or near-new condition or repaired as good as new. 2 Good Generally, the right number, size and layout of key clinical and clinical support spaces, and generally, the overall configuration of the department or unit is appropriate for the model-of-care. Clinical department or unit displays limited deterioration that does not affect its use. Minor maintenance may be required. 3 Average Likely to be too few key clinical and clinical support spaces. Some may be the right size while others are too small. Layout of key clinical spaces may be compromised. Some elements of the overall configuration of the department or unit may compromise the model-of-care. Clinical department or unit has deteriorated to a degree where maintenance is obviously due. 4 Poor Generally, too few key clinical and clinical support spaces. They are generally inadequately sized and may have a poor layout. The overall configuration of the department or unit does not support the model-of-care. Repair or renewal is required as facility condition is severely impacting clinical safety and performance. May pose health and safety issues. 5 Very Poor Too few key clinical and clinical support spaces. They are inadequately sized and likely to have a poor layout. The overall configuration of the department or unit does not support the model of care. Immediate repair or renewal is required as the facility’s condition is severely impacting clinical safety and performance. May pose health and safety issues and requires urgent attention. Mental health units The 24 mental health units assessed were selected from buildings built before 2010. This included 21 acute units, 1 extended care, 1 rehabilitation, 1 psycho-geriatric and 1 intellectual disability unit. The bed numbers for the wards in these units ranged from 7 to 40, with the largest unit at Auckland DHB accommodating 62 overall. Around 70 percent of the units have designs that do not provide adequate privacy, safety and therapeutic space to support different diagnoses, stage of illness, culture, gender and age. Managing patients with different needs in a poorly designed unit is 39 difficult for staff and challenging for patients. The problem is exacerbated in the units with fewer beds and fewer options to separate patients. Many units lack consideration of the cultural needs of their clients. Cultural spaces, whānau rooms and areas suited to pōwhiri are important for New Zealand mental health facilities. While the Australasian Health Facility Guidelines do not specify these spaces, they do recommend that entry, reception and waiting areas are welcoming and respectful. Tiaho Mai at Middlemore Hospital has a whare entrance, and at Tauranga Hospital, there is a large whānau room with outdoor access used to welcome people. Strategies to cope with excess demand were evident in 70 percent of the units. These included using day, seclusion, interview and meeting rooms as bedrooms. Periodic leave is an important part of the person’s transition, but some bedrooms were used for new patients while their occupants were on leave in the community. Interior maintenance at 70 percent of the units was poor, including poor paintwork, holes in the walls, leaks in ceilings, rippling and worn carpets and poor bathroom facilities. Maintenance was good at the Southland Hospital unit, the older persons unit at Kenepuru Hospital, Kensington in Timaru, and Waiatarau in Waitematā. Mean scores for nine design principles For mental health inpatient units, the key principles involved in poorer scores include: • lack of privacy for recovery • inadequate support for staff and patient communication related to poor line-ofsight for observation • poor lighting in treatment areas and lack of access for staff to computers • insufficient door sizes and corridor widths for people to circulate and to access therapy areas inside and outside the unit • for stand-alone units, the distance for access to other clinical services should electro-convulsive therapy (ECT), intensive care and radiology services be required. Investigation is required to identify the opportunities to address these issues. Initiatives could include a mix of changes to models-of-care, strengthening community-based alternative services, targeted refurbishments and unit renewal. Figure 13: lists the older mental health units and wards (W) assessed, along with the control unit. It shows the mean overall scores on the nine design principles ranged from good to very poor, with 3 good, 6 average, 11 poor and 4 very poor. The unit at Hillmorton provides psychiatric and intellectual disability services (PSAID). The control unit Tiaho Mai was among three with a good score. 40 THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS Figure 13: Mean scores on nine design principles for mental health units 14 Very poor Poor Average Good Very good Average score on nine design principles 5 4 3 2 1 0 Gross floor area Most (75 percent) of the units are smaller than the AHFG benchmark of 80m2 per bed, and many have undersized bedrooms. While a significantly undersized unit can compromise service delivery, larger units can also be poorly designed. Six units including the control unit at Middlemore are larger than the benchmark size, but within an acceptable size range. The gross floor area findings for all units assessed are set out in Appendix 3, Table 22. Unit configuration Over 50 percent of the units had various features common to designs first developed for prisons, which do not support modern requirements for safe, quality care for staff and clients. These features include: • having bedrooms on both sides of the corridors with doors opening outward into the corridor, which reduces privacy and compromises the space for circulation • having shared bedrooms, shared bathrooms and shared toilets with partial partitioning, which is not compatible with privacy, cohort management, safety and recovery • a central glass-enclosed staff base that gives people-in-care a sense of being watched, and provides no privacy for staff to complete their work • dead-end corridors that are inflexible for cohort management, and create a risk that staff become trapped with an agitated person • angular geometry with high sloping or raked ceilings that are not associated with a restful supportive environment for recovery • outdoor spaces entirely external to the unit and fenced, that do not support flexible indoor to outdoor space for different cohorts 14 DHB names are abbreviated. See Appendix 2 for definitions. 41 • inadequate separation of spaces between the individuals being treated, the public and the staff. In contrast, the Tiaho Mai control unit at Counties Manukau DHB is the first example of the new courtyard model, which features: • wide circulation areas around enclosed courtyards • separation of spaces for people acutely unwell and those in step-down care • smaller shared living spaces • separate and therapeutic areas for interaction among the person in care, whānau and the staff • off-the-floor staff work areas • separate access pathways for staff, acute admissions and the public • more subtle sophisticated security arrangements. Most (80 percent) of these older units’ lack spaces for different aspects of therapy compared to the guidance in the AHFG. This includes interview rooms, patient and whānau areas, sensory rooms or gardens, dining rooms, kitchens, activity rooms, lounges and outdoor spaces. Therapeutic spaces are required by a range of staff, including mental health nurses and assistants, social workers, psychologists, psychiatrists, occupational therapists and cultural advisors. Only half of the units have adequate outdoor space. Helensburgh at Wakari campus Southern DHB is located on the third floor and has no outdoor recreation area. Te Whetū Tāwera at Auckland DHB and Ward 11 at Hauora Tairāwhiti Gisborne Hospital have very limited outdoor space. The Henry Bennet unit at Waikato DHB has constructed two bedrooms from a single room, which compromises privacy and access to external windows. The North Shore older persons unit has several multiple-bed bedrooms, which offer no privacy or ability to separate patients according to gender, age, acuity, diagnosis or cultural needs. Only three units – Gisborne, Tiaho Mai and Invercargill – provide en-suite bathrooms for each bedroom. The rest have either a mix of en-suite and shared bathrooms or only shared bathrooms. Safety Safety issues included: 42 • keyed access to doors, rather than electronic swipe card keys • dead-end corridors where the patients and staff can be trapped • bedrooms on both sides of corridors with doors that open outward into the corridor, obstructing access and observation • lack of required anti-ligature fittings. THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS Most units had just a single clinic room for dispensing medication. Single-point and poorly located dispensaries compromise patient management, as the patients congregate around the clinic. Emergency departments Nine emergency departments were assessed, nearly half of all departments nationwide. Included were the Northland, Counties Manukau, Hawke’s Bay, Tairāwhiti, Lakes, Taranaki and South Canterbury DHBs. The control unit at Waikato DHB was selected due to its location in a newer facility. Capital & Coast DHB’s Kenepuru unit was assessed; however, it operates as an after-hours general practice rather than an emergency department. All emergency departments have similar models-of-care, with triage to direct people for minor and more complex problems, and resuscitation areas. Most departments have experienced significant increases in demand over the last five years. Some departments report difficulties managing people who require a mental health assessment, due to a lack of suitable space. Mean scores for nine design principles For emergency departments, the key principles involved in poorer scores include: • infection control issues related to suboptimal separation of patients, separation of clean and dirty workflows, and the quality of surface finishes • lack of privacy for people being treated • poorly sized and shaped spaces for key clinical work. Figure 14: lists the older emergency departments assessed, along with the control department. It shows the mean overall scores on the nine design principles ranged from good to poor, with 2 good, 3 average, and 6 poor. Kenepuru was the only accident and emergency department included. The control department at Hamilton Hospital scored average. 43 Figure 14: Mean scores on nine design principles for emergency departments Gross floor area Over half (64 percent) of the emergency departments are undersized against the AHFG benchmark of 50m2 per bed, and all have undersized bays for patient treatment. For 50% of emergency departments, most bed bays are undersized compared to the AHFG bay sizes for acute treatment at 12 m2, patient resuscitation at 25m2 and trauma at 30m2. The smallest emergency department compared to the AHFG benchmark is Whangarei at 38%. Departments at Timaru and Palmerston North are also unacceptably small. Three departments, the Kenepuru accident and emergency, Middlemore and Wairau are above the AHFG benchmark. The control unit at Waikato is also above at 104%. The gross floor area findings for all units assessed are set out in Appendix 3, Table 18. Unit configuration Just under half (40 percent) of the departments have layouts that do not support their models-of-care. To accommodate demand, Whāngārei, Palmerston North, Gisborne, Timaru and Hastings have incrementally incorporated space from adjacent areas. The resulting layouts are piecemeal, with: • cramped conditions • suboptimal configuration for a functional flow of care • lack of safe separation of patients • lack of natural light. A further 50 percent of the departments have some of these problems. Only Wairau has both a layout and the space necessary for a modern model-of-care for an emergency department. 44 THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS Almost all (90 percent) of the departments lack adequate clinical spaces to support patients who need: • a single room • isolation for infection control • privacy for mental health assessments • paediatric care • obese or bariatric facilities. A further problem is the use of enclosed single door spaces for mental health assessments that do not meet the AHFG benchmark of two exits, necessary for staff safety. Safety The difficulties with undersized bed bays, suboptimal layout and corridors cluttered with equipment compromise the safety of staff and patients. Issues include: • infection control because cleaning is compromised • obstructed access in thoroughfares, which can contribute to injuries for staff, patients and visitors • trip hazards from equipment and cables, which can contribute to injuries for staff, patients and visitors • risk of work injuries from lifting items stored on floors or at height. In over half (70 percent) of the units, staff could observe less than half of their patients from a clinical workstation. This compromises patient safety and places additional demands on staff. Whangarei where just 26 percent of patients were within direct lineof-sight from a staff base, had the poorest score. The best was the control unit at Waikato, with 59 percent of patients visible from a staff base. Storage None of the emergency departments assessed have adequate storage. Corridors are cluttered with extra beds and transport trolleys, trolleys for diagnostic tests and treatments, patient mobilisation equipment, electronic clinical devices, portable X-ray machines, computers-on-wheels etc. There is inefficient storage for supplies, and inadequate space for disposal of rubbish, waste and soiled linen. Other issues Most units (80 percent) reported they have inadequate facilities for bariatric patients, including designated treatment spaces and ceiling-mounted lifting devices. Not all units had a permanent security presence. Many (40 percent) reported increasing security concerns, particularly the management of people with presentation related to drugs and alcohol related presentations. 45 Operating theatre suites Nearly half (15) of operating theatre suites nationwide were assessed at 11 of the 20 DHBs. These included units in Northland, Auckland, Counties Manukau, Tairāwhiti, Waikato, Lakes, Hawke’s Bay, MidCentral, Capital & Coast, Nelson Marlborough, and Canterbury DHBs. Canterbury DHB’s Burwood was selected as the control unit due to being in a newer building. These units perform planned and acute surgeries, except for the elective surgery centre at the Manukau SuperClinic. Over half (60 percent) of theatres reported that demand exceeds capacity. All theatres operate 8am to 5pm, five or six days per week, and afterhours for urgent cases. There is limited ability to increase volumes of cases within existing facilities. Mean scores for nine design principles For operating theatre suites, the key principles involved in poorer scores include: • infection control issues related to suboptimal separation of patients, separation of clean and dirty workflows, and the quality of surface finishes • lack of privacy for people receiving surgery • poorly sized and shaped spaces, especially operating rooms. Figure 15: lists the older operating suites assessed and the control operating suite. It shows the mean overall scores on the nine design principles ranged from good to very poor, with 4 good, 6 average, 4 poor and 1 very poor. The control suite at Burwood was among those with a good score. Figure 15: Mean scores on nine design principles for operating theatre suites Very poor Poor Average Good Average score on nine design principles 5 4 3 2 1 0 46 THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS Very good Gross floor area Nearly half (40 percent) of the theatre suites were under the AHFG benchmark of 280m2 per operating theatre. The smallest was Starship at 76%, and the largest was Burwood at 125%. Over half (53 percent) report their operating room sizes are too small, and 33% have a mix of acceptable and undersized operating rooms compared to the AHFG room size. Since many of these units were constructed, operating room sizes have increased to accommodate advances in clinical and information technologies. The AHFG sizes for general surgery rooms were updated in 2018, and for day surgery and procedure rooms in 2016. Only Wairau and Burwood have adequate numbers of operating rooms at the AHFG sizes. These findings considered the size of different types of operating rooms, including: • • • • • 75m2 for rooms in a high-technology imaging and robotics suite 60m2 for rooms a general surgical suite 42-55m2 for rooms in a day patient surgery suite 17m2 for day procedure, endo and colonoscopy rooms 24m2 for dual layout day procedure rooms. Starship’s newest operating room and Wairau’s new private operating room met the general surgical suite benchmark at 60m2. All operating rooms at Burwood were 64m2. The gross floor area findings for all units assessed are set out in Appendix 3, Table 20. Unit configuration Over half (67 percent) of theatre suites have a layout that only partly supports their model-of-care, from patient preoperative preparation, to theatre rooms and postanaesthetic care. The layouts at Timaru, Gisborne and Starship do not support their model-of-care. Nearly half (40 percent) of the theatre suites have issues with the separation of their clean and dirty workflows. This includes Starship, Gisborne, Christchurch Parkside, Whāngārei, Greenlane and Hamilton. Burwood, Timaru and Palmerston North have partial separation. The remaining six have a clear separation between these two flows. Half (53 percent) of theatre suites reported that all their operating rooms are too small, and around 30 percent have only some rooms that are appropriately sized for their purpose. Two DHBs also had operating rooms with ceiling heights below 3.0 m, which created difficulties for manoeuvring around the ceiling-mounted equipment. Safety Over half (70 percent) of units have direct line-of-sight from the staff workstation for all their patients in the post-anaesthesia care area, which is crucial for patient safety. However, four units (27 percent) had less than 100 percent visibility. Greenlane has none due to poor layout and the location of the structural columns. 47 Unit issues contribute to difficulties with infection control through cramped patient areas; older floor, wall and ceiling surfaces that are hard to clean; and poor separation of clean and dirty workflows. Storage Most (80 percent) of the theatre suites lack storage space for the increased volumes of prepacked supplies, consignment and loan instruments, implants and specialist clinical equipment. Only Nelson and Kenepuru had fewer storage issues, while Wairau had none. Intensive care units Nearly half of the intensive care units nationwide were assessed. Of these 10 units, there are 9 that care for both intensive care and high-dependency patients, including Whāngārei, Starship, and Waitematā, Counties Manukau, Waikato, Tairāwhiti, Hawke’s Bay, MidCentral and South Canterbury DHBs. Starship is a paediatric unit. The control unit at Waikato DHB, selected due to its location in a newer building, is a specialist intensive care unit. Mean scores for nine design principles For intensive care units, the key principles involved in poorer scores include: • infection control issues related to suboptimal separation of patients, separation of clean and dirty workflows, and the quality of surface finishes • lack of privacy for people in care • poorly sized and shaped spaces for key clinical work. Figure 16: lists the older intensive care units assessed and the control unit. It shows the mean overall scores on the nine design principles ranged from average to poor, with 3 average and 7 poor. None of these intensive care units that are over 20 years old achieved a good score on the nine design principles. The control unit at Hamilton Hospital scored had the best score. 48 THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS Figure 16: Mean scores on nine design principles for intensive care units Gross floor area The AHFG benchmark for intensive care is 85m2 per bed for units with fewer than 15 beds, and 70m2 per bed for those with more than 15 beds. Most (80 percent) of units are beneath the benchmark. The control unit at Waikato is 118% of the AHFG. Over half (70 percent) of the units have bed spaces under the AHFG bed space size of 24-25m2, while the remainder have some bed spaces compliant with the AHFG. The gross floor area findings for all units assessed are set out in Appendix 3, Table 19. Unit configuration Most (80 percent) of the intensive care units have insufficient enclosed patient bays to support their mix of patients. The AHFG recommends a range of enclosed and open patient bays for the effective management of patients and infection control. At Taranaki, the unit has been built in a U-shape around a large plant room. This obstructs patient observation across the unit, and allows little space for clinical support spaces, staff and storage. At MidCentral and Gisborne, all patient bays are too small, and key clinical and clinical support spaces are missing. Palmerston North, Hawke’s Bay and Timaru have only one point of entry to their units, used for patients, staff, visitors, delivery of goods and removal of dirty linen and waste. Additionally, Timaru has to use an access ramp to their single point of entry. Safety Patient observation is compromised at: • Taranaki due to the design around a large plant room 49 • Starship due to the multiple-bed bedrooms • Middlemore due to the layout and column location. Palmerston North, Gisborne, Hawke’s Bay and Timaru have significant infection control issues due to cramped units, inadequate negative-pressure rooms and storage issues, along with suboptimal surface finishes and maintenance. Storage Almost all units have inadequate storage. The Starship paediatric unit has significant problems storing age-related beds and equipment for 0–19 years. Most storage at Taranaki and Middlemore is outside the unit. Other issues Apart from Timaru, all units have negative-pressure bedrooms. However, only four meet AHFG size recommendations, which are bedrooms of 25 m2 with dedicated anterooms of 6 m2 and typically en-suite bathrooms of 6 m2. Provision of negative-pressure bedrooms is essential for managing patients who are infectious. Issues include inadequately sealed rooms, use of a corridor as an ante-room, and shared ante-rooms. Three units have significant issues with the location of medical gas and suction services, including: • Gisborne, where floor-mounted bollards under the head of the bed mean staff crouch under the bed to operate them, and they obstruct clinician access to the patient’s airway • Timaru, where floor-mounted bollards beside the bed create difficulties for staff to operate them and to access the patient • Hawke’s Bay, where ceiling-mounted bollards have poorly maintained articulated arms, which are hard to position and maintain in position. Almost all units (90 percent) have inadequate facilities for bariatric patients, including designated treatment spaces and ceiling-mounted lifting devices. Inpatient units DHB staff nominated an inpatient unit from the 19 ward-blocks over 20-years old, at 13 DHBs. These units ranged from 20–43 beds and included medical, surgical, orthopaedic, rehabilitation and older persons care. Included were units at the Northland, Auckland, Counties Manukau, Waikato, Bay of Plenty, Tairāwhiti, Hawke’s Bay, Whanganui, MidCentral, Capital & Coast, Hutt Valley, Nelson Marlborough and Canterbury DHBs. Challenges were observed for the care of patients in units with multiple models-ofcare. For instance, the Whāngārei paediatric unit has medical and surgical care, inpatient and outpatient care, along with child protection and mental health cases. This 50 THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS complicates the workflow, the separation of patient cohorts, and the use of clinical spaces. All units reported excess demand, which has implications for increased staff stress and risks to the quality of care. Mean scores for nine design principles For inpatient units, the key principles involved in poorer scores include: • infection control issues related to suboptimal separation of patients, separation of clean and dirty workflows, and the quality of surface finishes • lack of privacy for people being treated • inadequate support for staff and patient communication related to poor line-ofsight for observation, poor lighting in treatment areas and lack of access for staff to computers • poorly sized and shaped spaces for key clinical work. Figure 17 lists the older units and wards (W) assessed, along with the control unit. It shows the mean overall scores on the nine design principles ranged from good to very poor, with 2 good, 3 average, 13 poor and 2 very poor. The newer control unit Ward A3 at Waikato DHB was among those with a good score. Figure 17: Mean scores on nine design principles for inpatient units Very poor Poor Average Good Very good Average score on nine design principles 5 4 3 2 1 0 Gross floor areas The AHFG benchmark for inpatient units is 36m2 per bed. Over half (70 percent) of the units are at or beneath the benchmark. All units have problems with the size of bed spaces in both single and multiple bed rooms. Over half (70 percent) of units were undersized to the AHFG, while the remainder had some bed spaces compliant with the AHFG. The gross floor findings for all units assessed are set out in Appendix 3, Table 21. 51 Unit configuration Compared to older units, modern unit designs aim to optimise the natural light for patients, have more single bedrooms and en-suite bathrooms, enable staff access to and observation of patients, and have easy access to areas for utilities and storage. Newer units generally accommodate these requirements through increased width and a larger floor space. The 2019 assessments included 9 single-corridor and 11 racetrack style units. The single-corridor configuration usually has multiple-bed bedrooms on one side and single bedrooms, patient amenities, the nursing station and utilities on the other side. Racetrack wards are wider than single-corridor wards, with multiple-bed bedrooms and single bedrooms around the outside, and the nurses’ station, patient amenities, utilities rooms and storage in the centre. People circulate around the centre, hence the name ‘racetrack’. Each style has difficulties that newer designs attempt to address. Safety The clutter in bedrooms and corridors has safety implications, including: • infection control because cleaning is compromised • retrieval of stored items with implications for staff injury • obstructed thoroughfares, which impact staff, patients and visitors • trip hazards from equipment and cables, which impact staff, patients and visitors. Patient observation is a critical element of clinical care. Generally, the single-corridor wards have one nurse-base located centrally, which severely limits patient observation, such as at the Nelson orthopaedic ward. Some newer racetrack configurations have distributed nurse-bases. This is evident at Greenlane’s surgical day-stay and in the control unit at Waikato, where nurse-bases are distributed closer to patients’ bedrooms. Modern unit designs have decentralised staff-bases to enable observation of higher dependency patients. The assessors observed improvisations in the older units, including a nurse-base installed in the trauma room of the Christchurch orthopaedic unit, and a nurse-base in the Whāngārei rehabilitation unit located in a dead-end corridor to enable observation of the higher acuity patients in an adjacent multiplebed bedroom. There are a wide range of design issues that affect infection control. These include whether the floor, ceiling and wall-finishes are easy to clean; whether there is separation between service, patient and visitor flows; and whether there is adequate storage and waste disposal. Seventy-five percent of the units scored poorly across all of these issues. Storage Most units (80 percent) had a lack of storage due to the increased demand for supplies and electronic and rehabilitative equipment. This is evident across all specialities, 52 THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS including medical, surgical, orthopaedic, spinal and rehabilitation care. These difficulties with size and storage space were expected as these units are in buildings over 20 years old. The changes to short hospital stays with intensive treatment on wards have increased the demand for storage. In older facilities, the space around each bed was designed to include a patient’s dresser, wardrobe and tray tables, and a visitor’s chair. Wards also had medication, linen and supply storage, and some equipment such as commodes, bed cradles and dressing trolleys. Today, there is an array of additional equipment on inpatient wards, including electronic monitoring devices and infusion pump units, large portable hoists, bedside diagnostic devices like electro-cardiographs and portable ultrasound, computers-onwheels, and charging and storage bays for portable electronic equipment. Early mobilisation of patients involves equipment like walking frames, patient bedside chairs, wheelchairs and crutches, along with accommodating more intensive therapy work on the unit. Medication storage has also changed to accommodate more pre-packaged formulations and regulatory guidelines. Some wards retrofit secure specialised medication dispensaries within the unit. Further analysis could identify opportunities to improve storage hospital-wide and locally in units. For instance, clever storage systems are evident at the Waikato intensive care unit. When equipment is cleverly installed and easy to access, it can facilitate safe and efficient workflow within the unit. There may also be opportunities to redistribute storage in the hospital. Other issues Over half (65 percent) of the inpatient units do not have or require negative-pressure bedrooms for their model-of-care. Of the seven units with negative-pressure bedrooms, only two are compliant with the AHFG. Issues identified include shared ante-rooms, shared bathrooms, poor door seals and inadequate patient observation panels. These older units were built prior to the introduction of the AHFG, and lack components in their construction needed to support negative pressure rooms. There appears to be a poor understanding of the AHFG for negative-pressure rooms, a problem also observed in the intensive care units. Most (85 percent) of units do not have enough facilities for obese or bariatric patients, such as bariatric beds, hoists and equipment. The exception is the medical ward at Waikato, however at the time, most of the ceiling-mounted lifting hoists were nonfunctional due to a technical issue with the supplier. The two paediatric wards did not answer this question. 53 Section 4 Information technology DHB IT is largely focused on core hospital systems, with asset management practice constrained by a short-term planning focus. Investment of around $2.3 billion is required over the next 10 years to address issues with legacy systems and to invest in technologies that enable services to transform to new models-of-care. New Zealand has lacked the investment levels necessary to embrace rapid changes in health IT technologies. It is estimated that DHBs spend 2.3 percent of their operating budgets on IT, with 90 percent going to support aged and outdated systems, and infrastructure. According to Deloitte (2015), this needs to shift to 4.6 percent, with 75 percent spent on maintenance and 25 percent on new investments. Over the last 10 years health professionals have changed from acceptance of departmental legacy systems to expectations that systems support the clinical workflow. This includes support to view and update an integrated patient record, on-the-move, across all care settings, and on various devices. A significant lift in investment of around $2.3 billion is necessary to deliver this digital health environment.15 DHBs have maintained their IT assets in an environment of accumulated underinvestment. Audits have shown that IT strategy, governance and asset management have operated at a basic level (Morrison Low 2018). There are multiple versions and customisations of core applications, ageing infrastructure, limited network capacity and devices not fit-for-purpose. This reduces productivity, increases costs for maintenance and support, and increases cyber security risk. Further, the slow adoption of systems compliant with national data standards limits information sharing across clinical settings, and with consumers. Consequently, system users resort to various ‘workarounds’ to overcome lack of access, multiple logins, poor response times and the lack of alignment with clinical workflows. This means the productivity and quality benefits of clinical IT systems are not being realised. Health IT is likely to move to a 40:60 percent split between capital investment and operating expenditure through ‘as a service’ solutions. This will enable DHBs to move 15 54 Calculation based on DHB 2018/–19 operating expenditure and 2.2 percent per annum to lift investment levels to the 4.5 percent benchmark. THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS away from reactive management of complex technology environments, to the development of IT solutions as enablers for the clinical workflow, improved data analytics, and new models-of-care. Modernising technology solutions will also reduce the costs associated with maintaining the diverse skill-base required in the current mix of legacy and newer technologies. Development of a consistent nationwide picture of the fitness-for-purpose of IT assets will contribute to the prioritisation of long-term capital investment. This section begins with the assessment approach, then provides an overview of the digital health environment. Next it reports the condition scores for selected core applications in DHBs. The section then looks at the slow progress with the adoption of four national data standards important for health information sharing, system integration and workforce collaboration. The section concludes with an outline of the condition of a sample of infrastructure, networks and security. Assessment approach This is an initial assessment. The sources for these assessments include: • Two national surveys for assessment of core applications, although neither were specifically designed as asset management surveys. • Two case studies, one from the Northern Region’s Information Systems Strategic Plan (ISSP) and other a review by Hutt Valley Health, along with information held by the Ministry of Health informed assessments of the digital health environment, the adoption of national data standards, and the condition of the infrastructure. To support future assessments, in 2020/21 a more detailed and robust assessment will be developed in collaboration with DHBs. The approach will be similar to that used for the 2019 assessments of buildings, infrastructure and clinical facilities. It will be designed for IT and clinical equipment, and consider asset lifecycle, condition and fitness-for-purpose. There will also be work on asset levels-of-service. Table 11 sets out the asset types, sources of data, assessment content, and sample size for this current-state assessment. 55 Table 11: Data sources for health digital technology assessments Asset type Data sources Assessment Sample size Digital health environment Northern Region ISSP, Hutt Valley Health case studies and information held by the Ministry of Health Narrative and some statistics on demand growth, fragmented systems, and complex IT environment 25% of DHBs Core applications Grade scores from DHB digital Combined grade and systems landscape survey 2019 condition score Condition scores from national Government Chief Digital Officer survey of top 20 critical systems 2018 20% of core applications for all DHBs Data standards Northern Region ISSP and information held by the Ministry of Health Narrative on slow progress and the implications Applies across all DHBs Infrastructure Northern Region ISSP Narrative and some statistics on grade, condition and functionality 20% of DHBs The Northern Region’s Information Systems Strategic Plan (ISSP) is a significant case study as the four DHBs operate similar IT systems to other DHBs. The region covers 20 percent of all DHBs, and 39 percent of the New Zealand population from urban Auckland to rural Northland. Work will be completed in 2020 on a methodology for assessments of IT and clinical equipment assets. Digital health environment The mobility of the IT landscape has changed dramatically since the widespread adoption of smart phones and similar devices in the late 2000s. Clinical staff expect patient and clinical information to be accessible to view, for collegial discussion conversations with patients, and to update on-the-move between patient care areas, offices and community settings. Yet realisation of these expectations is constrained by limitations in funding, infrastructure, legacy applications and the slow adoption of national data standards for interoperability. DHBs collaborate to varying degrees, as individual organisations and as regional groups. The focus of the collaboration varies, such as the shared management of infrastructure through the joint ownership of the healthAlliance by the four northern DHBs; and the sharing of clinical data through a read only portal across South Island DHBs and community providers. Despite such progress, the core systems that manage hospital departments are seldom shared instances. Additional local systems are also used to integrate information and support clinical-work, but functions are limited and implementation slow. In 2018, an IT business impact review was completed by Hutt Valley DHB that revealed an 800 percent growth in applications, mostly in clinical areas, in little over a decade. The growth included high dependency on Wi-Fi and mobile phones with applications seen as critical to service delivery and patient safety. The implications for IT 56 THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS management include: significant cyber security risks; requirements to support both legacy and new technologies, and the need for staff to have a diverse range of technology skills. This complexity focuses effort on maintenance rather than on IT as an enabler of workflows and new models-of-care. Another review in 2018, in the Northern Region, found over 1,200 applications across its four DHBs. Yet only 10 percent of these applications appeared to be up to date, with the rest obsolete or becoming obsolete. Application lifecycles were poorly managed, deployment was not responsive to the business, and there was a lack of automated application testing. The explosion in demand exacerbates the problems with bespoke and departmentally specific systems that are widespread due to: • the role of senior medical staff as primary influencers in purchases of IT and clinical equipment related to their own area of specialty. The result can be a complex siloed environment with limited data sharing, and expensive to maintain over the lifecycle of the assets • lack of investment in the IT infrastructure necessary to keep pace with this clinical demand for applications, devices and network capacity to access information onthe-move across the organisation • lack of attention to, and funding for IT implementation, including clinical process standardisation, comprehensive design of application configurations, and the change management important for an integrated organisational approach to IT investment • little attention to the advantages and slow adoption of the national standards to support data-sharing between applications. There is a multi-layered environment of clinical data generation, access and reuse within health services. A range of data views are required to support both clinical and management tasks such as: • accessing a macro view of a patient’s clinical history through different care settings • electronic whiteboard displays of the status and location of all patients in a treatment area such as an emergency department or ward • analysis of different patients and episodes of care as part of planning and performance review. When health professionals find systems difficult to access or use, they resort to workarounds with paper forms, email and smart phones. This undermines the integrity of data repositories and compromises the value of information for the clinical workflow and management analysis. Table 12 lists elements of IT systems important for health professionals to access systems. Issues include: • multiple sign-ons • ageing devices, phone and paging systems • applications incompatible with some devices 57 • use of insecure and non-integrated systems. Table 12: Access barriers to clinical information and collegial communication Access Issues Sign-ons Multiple sign-ons to network and clinical applications increase complexity for users. Devices – mostly desktop PCs DHBs may have up to 6,000 devices. It is common for these to be used beyond their expected life, eg, in the Northern Region the Win 7 operating system is out-of-support in January 2020. Device application compatibility Many applications are not configured or approved for tablets and phones. Remote access Mostly Citrix. Few applications support smart phone access. Phones Various ages of Private Automated Branch Exchange (PABX) systems with poor capacity for smart phone use. There are 70 PABX systems in the Northern Region. Paging systems Obsolete. Corporate collaboration Lack of digital clinical collaboration space, which means personal smart phones and email are widely used for clinical communications. Core applications There are multiple instances and versions of core applications, and customisation is common. Data from the 2019 DHB digital systems landscape survey shows approximately 21 core applications in DHBs, including: • corporate applications like financial management, inventory management, payroll and human resources • core patient administration systems found in all DHBs, along with specialised systems like mental health and maternity found in some DHBs • clinical department applications for laboratories, radiology and pharmacy, along with a clinical portal found in all DHBs, and medicine charting, radiology and laboratory orders, and general practice referrals in some DHBs. There are many other applications and various interfaces among these. Even so, many elements of patient records have remained paper-based, particularly at the bedside and treatment bay. Systems need to be expertly designed and configured to support the workflow. Implementation requires significant change management and deployment of large numbers of devices to capture all record-keeping on-the-move for health professionals. Assessment Selected for this assessment were 5 of approximately 21 core applications used across management and clinical operations. These included financial management, patient 58 THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS administration, clinical portals and pharmacy management used by all DHBs, and one newer application for medication charts used by eight DHBs. The assessment scores are derived from a combination of the condition and deployment scores. Table 13 depicts the matrix used to analyse information from the Ministry of Health’s 2019 DHB digital systems landscape survey and the 2018 Government Chief Digital Officer survey. Table 13: IT asset condition and deployment assessment scores Deployment Condition Multiple local Single local Shared Modern n/a 2 1 Current 4 3 2 Legacy 5 4 3 The condition scores relate to: • • • Modern – A well-managed IT environment with a system generally within its 7year lifecycle, which could include some elements of ‘as a service’ delivery for infrastructure and applications Current – A system that may be older than its 7-year lifecycle but has an upgrade path and support available, which may have elements of ‘as a service’ delivery Legacy – Older vendor product or bespoke system, with no upgrade path, very limited compliance with national standards and generally more expensive to maintain. The deployment scores relate to the number of instances of the asset. • Multiple local – There are multiple versions of the asset within the organisation, which can relate to a history of separate decision-making at different sites and fragmented management of asset renewal. • Single local – There are single versions of the asset with a strategic approach to upgrades and renewals. • Shared – The asset is managed through shared purchasing, maintenance and replacement or upgrade arrangements among DHBs or at a national level, which is designed to optimise both the solution and its lifecycle cost. The scores were: Very poor Poor Average Good Very good Corporate systems: financial management systems Figure 18: shows the finance systems were assessed as average to very poor in 14 of the 20 DHBs, with 10 poor and 4 average. There were 2 assessed as good and 4 as very 59 good. The systems rated average to very poor should each have upgrade plans in place, although this information was not sought for this assessment. Figure 18: Assessment scores for financial management systems Patient administration systems Core patient administration systems have a central patient index and support services for the management of medical records, inpatient admissions, outpatient appointments, emergency department and theatres, along with some other functions. Some DHBs use separate systems for emergency department and theatre. Other specialised patient administration systems include maternity, mental health and general practice referrals. There are 26 core patient administration systems due to legacy systems retained at specific hospital campuses. Figure 19: shows 12 DHBs with patient administration systems assessed as average to very poor (8 average, 2 poor and 2 very poor). There are 6 good and 2 very good. Figure 19: Assessment scores for patient administration systems 60 THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS Clinical support systems The main clinical support departments of radiology, laboratory and pharmacy have specialist information systems. These clinical support systems each have subsystems, including in pharmacy for inventory management and medication dispensing, in laboratory a subsystem for each specialist laboratory department, and in radiology for department management and for image capture, storage and retrieval. These systems also include interfaces to a range of clinical equipment to capture inventory and clinical data. Pharmacy was selected for this assessment; laboratory and radiology systems will be considered for the next assessments. Figure 20: shows that 13 DHBs have pharmacy systems assessed as very good. There are 7 assessed as average to very poor (3 average and 4 very poor). Figure 20: Assessment scores for pharmacy management systems Clinical portals Clinical portals enable health professionals to view patients’ information across different organisations such as general practices and other DHBs. Generally, to update a patient’s records, health professionals must sign-on to different systems. There is no integrated workspace for health professionals to appraise clinical information and generate actions to progress the activities of care. Figure 21: shows for the 20 DHBs, 9 clinical portal systems were assessed as good to very good (4 good and 5 very good). There were 10 average and 1 very poor. 61 Figure 21: Assessment scores for clinical portals Order entry and medication charts Order entry systems and electronic medication charts operate at the interface between patient care areas in places like emergency departments, wards, clinics and theatres and the clinical support departments of laboratory, radiology and pharmacy. DHBs typically have a range of order entry systems for laboratories and radiology, both electronic and paper based. Modern order entry systems should provide an integrated workspace for ordering and reviewing of assessments. To be effective, these systems depend on an IT environment that supports on-the-move access to systems for health professionals, and adequate change management to standardise the clinical processes. Like the order entry systems, electronic medication charts operate between the clinical care delivery at the bedside and treatment bay, and the pharmacy systems. Electronic medication charts are relatively new in New Zealand, and implementation can range from a few patient care areas to organisation-wide. Figure 22: shows electronic medication charts implemented in 8 of 20 DHBs, with 2 assessed as very good and 6 as average. Figure 22: Assessment scores for electronic medication charts Very poor Poor Average Good Very good Assessment Score 5 4 3 2 1 0 Shared health record repositories hold patient and clinical information from collaborating DHBs and different health information systems. The repositories supply 62 THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS information to support more integrated views of data, useful for systems such as, clinical portals, order entry, and electronic medication charts, along with district and regional analytics. Further work is required to develop an asset assessment approach for these repositories. Data standards, interoperability and analytics The Ministry of Health’s Health Information Standards Organisation (HISO) oversees the selection, development and adoption of all standards for interoperability in healthcare. However, adoption by the health sector has been slow and inconsistent. Clinical data comes from each core departmental system and there is limited interoperability for sharing among applications, to support work with patients and use the data for analytics. Work to improve core information systems and compliance with data standards, through the clinical workflow, is required to realise benefits from operating a more digitally enabled health system (Health and Disability System Review 2019, p 212). This slowness to adopt digital standards and coded forms of data has related to: • health professionals’ preference for text and reluctance to use coded forms of data in their clinical work • incomplete and poorly configured implementations of patient administration systems, and a lack of standardised approaches to data across multiple data repositories • lack of attention to strategies for enterprise reporting and analytics, other than the disease and procedures codes that are grouped for funding purposes at discharge from hospital • poor understanding of national and global standards as key enablers for quality, efficiency, information sharing and analytics. The Northern Region identified 100 core systems across the four DHBs with data important to the construction of a patient’s electronic record. However, the region lacked the necessary data standards and capability for integrated use. Capability issues included: • low scores on the Data Maturity Model at 1.6 out of 716 • separate business intelligence tools and analysts specialised for large applications, such as patient information, pharmacy, laboratory and radiology • lack of technical support for data security, due to out-of-date integration technologies and legacy security standards • risks to the integrity of patient data with limited monitoring, alerts and error management capability. In DHBs, the slow adoption of data standards is also evident in around 30–35 bidirectional connections for information sharing between patient administration and 16 Assessed by healthAlliance. 63 other systems, along with numerous interfaces between clinical systems and clinical equipment. The Health Level 7 (HL7) framework guides development of application programming interfaces, but this produces bespoke rather than reusable solutions, which are expensive to develop and maintain. The Northern Region identified 240 application programming interfaces on outdated integration platforms, with 50 percent being interfaces with core systems. HISO has endorsed four key national standards for the New Zealand health sector. These standards enhance productivity through entry and update of data once at its source, with a community of users able to access data with no re-keying. Progress with adoption is slow, despite the productivity opportunities. The four key national standards include: 64 • Systematised Nomenclature of Medicine Clinical Terms – SNOMED CT SNOMED CT is a global language of healthcare. New Zealand was a founding member of SNOMED International, which is a not-for-profit organisation formed in 2007 for ongoing development of SNOMED CT. Standardised clinical terms with common codes enable clear exchange and analysis of clinical data to improve patient outcomes. SNOMED CT codes apply to the entire clinical workflow, from a presenting yet undiagnosed condition to diagnostic tests, treatments and outcomes. At present there is discrete use of SNOMED CT in New Zealand by some clinical departments and general practitioners. • Global Standards 1 – GS1 GS1 provides unique identifying codes for organisations, parts of organisations, products and devices. It enables global e-commerce, facilitating transmission of unique product information, through the supply chains, including tracking, product advisories and recalls. In many developed countries, the health sector is the largest government user of GS1. Healthcare uses include procurement, and tracking materials, devices and medicines through health facilities and to patients’ bedsides. The New Zealand Business Number and parts of an organisation are GS1 location codes. One use is to enable visitor tracking, such as in the Ministry of Health’s Covid-19 tracker. New Zealand lags other countries with adoption, particularly in health. • New Zealand List of Medicines and formulary – NZULM NZULM is a unique identifier for funded and approved medicines in New Zealand. It is an application of SNOMED CT, which can support sharing of medicines information across hospital and community settings. There is also an alternative system with different codes in New Zealand, and slow adoption of both systems among general practitioners. • Health Level 7 Fast Healthcare Interoperability Resources – HL7 FHIR FHIR is the most recent of the HL7 standards that have existed for several decades. HL7 provides a framework to guide interface developments between applications in health. However, this produces bespoke interfaces that tend to be expensive to build and replace. Older applications do not support the FHIR version. Overall adoption of the SNOMED CT, NZULM and GS1 would also reduce the degree of variability in HL7 interfaces. THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS Infrastructure, networks and security These assessments were drawn from a review of the Northern Region’s four district health boards, completed by the healthAlliance. IT infrastructure assets include: • systems-as-a-service • data centres and computer rooms • shared record repositories • server operating systems • networks • security. Data centres DHBs are moving towards having regional data centres managed by specialist providers. They are also moving to ‘as a service’ and cloud-based services for some of their clinical repositories at an organisational or regional level. Typically, DHBs have large data centres along with campus-based local computer rooms with servers running applications. Data centres can be vulnerable due to the condition of the buildings and site infrastructure, and the data centre design and condition. This design includes flooring, climate control, uninterruptable power supplies, cabling and server racks. Poor condition risks system outages from failures and compromises safety for the technical staff directly involved. It entails significant risk for DHBs because service delivery depends on the continuity of information systems that support patients’ diagnostic and treatment processes. Illustrations of recent failures experienced by DHBs include burst water pipes flooding the computer room and fire caused by overheated uninterruptable power supplies. Assessments of the five data centres in the Northern Region showed these as mostly in average to poor condition. Issues include: • lack of capacity to support strategic initiatives, including moves to a regional patient administration system, collaborative community care, and improved management of user identity access • requirements to upgrade 50 percent of operating systems in 2020 to avoid being out-of-support, and to invest in capacity to increase space, power supply and cooling in 2020 • operating 60 percent of core systems without disaster recovery arrangement. Networks Networks in DHBs lack capacity and reliability to support on-the-move access to clinical systems for health professionals. Significant issues include: 65 • slow response times due to lack of capacity • loss of data integrity in a multiple-user environment • extended outages due to lack of network redundancy • variable Wi-Fi access across clinical settings • lack of capacity for Internet access for patients and visitors. In the Northern Region, 50 percent of the network infrastructure will be out-of-support by 2020. Multiple outages associated with network failures have lasted for up to 8 hours for Internet access and 72 hours for communication via the national secure network. Security Problems with DHB management of security related both to the complexity of legacy systems and to financial constraints. Issues include: 66 • lack of security policies and staff training • multiple applications with inconsistent functionality around user profiles and tracking of data views and updates • large numbers of users who work across different health organisations require access to several applications – these users can repeatedly join and leave each organisation as they move through cycles of training, without being removed from systems • lack of IT system configuration and tools to detect security attacks • lack of skilled IT staff to focus on security. THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS Conclusion and next steps The current-state assessment identifies the relative investment priorities using the consistent frameworks developed by the NAMP. The next steps are to develop a comprehensive work programme to deliver a National Asset Management Plan and continue to build the asset management capability and evidence-base across the health sector. Conclusion The development of consistent frameworks and asset management enablers such as the HART provide a good foundation for development of a National Asset Management Plan. The information and data provided has already been used by the Ministry. It will continue to inform investment prioritisation and the development of investment programmes. The current-state assessment provides evidence to determine the relative investment priorities, which include: • sitewide infrastructure (eg, pipes and electrical power) • building operability (eg, passive fire separation) • mental health and intensive care units, including CFFFP, condition and maintenance • core IT applications, including financial management, patient administration and pharmacy management systems. There are multiple trade-offs involved to prioritise asset improvement for health facilities. For example, there can be trades-offs between the resilience of buildings, clinical fitness-for-purpose and sustainability features. It will be useful to clearly set out the priorities and provide an integrated view of the necessary investment. Overtime, target asset levels-of-service and design standards will contribute to assurance that health facilities are fit-for-purpose over a range of asset performance objectives. 67 The NAMP is part of a government-wide agenda to ensure generations of New Zealanders receive best value from new and existing investments. Best value outcomes depend on improving the quality of capital funding decisions, asset management, and long-term investment outcomes. The Government has set clear objectives to have asset management plans in place to guide strategic, tactical and operational choices under Cabinet Office circular CO (6) 2019. The NAMP is intended to guide strategic choices at a sector level, and over time, it is expected that it will represent a consolidation of the DHBs’ asset management plans. The team involved in the development of the frameworks and current state would like to acknowledge and thank the DHBs’ staff who were involved in development of the current-state assessment. Next steps The Ministry is developing an asset management framework for the health sector and working on a more comprehensive, realistic and detailed work programme to progress asset management across the health sector. This will be aligned to resource levels and asset management standards such as the International Standards Organisation (ISO) asset management standards and the International Infrastructure Management Manual 2015. Table 14 sets out the asset scope being considered in the design of the programme of assessments for 2020/21. The findings will be presented as part of the NAMP second report in 2022. Table 14: Asset scope for the second NAMP report due in 2022 68 Asset type In-scope Target data completeness Target data confidence Buildings All IL3 and IL4 hospital buildings Building condition 100% Reliable Buildings at hospital campuses larger than 1,000 m2 50–100% Reliable Clinical facilities - Inpatient mental health facilities, including acute and forensic units 80–100% Reliable Infrastructure All sitewide reticulated systems (ie, plumbing, electrical, mechanical and critical utilities supporting campus services) 100% Reliable Information Technology All core applications at each DHB 50–100% Compliance with national standards 50–80% IT infrastructure, datacentres, networks and security 50–80% THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS Reliable (will be dependent on data from DHBs) Clinical equipment Other minor assets Large clinical equipment (eg, radiology including X-ray, ultrasound, gamma cameras, linear accelerators) 100% Reliable Smaller critical clinical equipment, shared across departments Sample 10–50% Reliable Sample 10–50% Reliable Criticality framework for minor assets established Critical minor assets The priorities to improve asset management through the NAMP include to: • further prioritise the work programme required to progress development of a national asset management plan for the health sector, in consultation with the Health Asset Management Improvement forum and to be approved by Capital Investment Committee • consult with DHBs and then publish an asset management strategy and policy for the health sector • complete an asset management framework for the health sector including development of an asset management plan template and guidance • continue to refine the data and presentation in the HART tool, including analytic and narrative ‘A3s’ for each DHB including campus data, and to make the tool available to appropriate DHB staff • develop an asset risk and assurance framework for DHBs • develop an asset sustainability work programme • develop and pilot a robust assessment for clinical equipment and IT in collaboration with DHBs • develop asset levels-of-service aligned to the national service design to quantify long-term investment scenarios • complete a second phase of clinical facility fitness-for-purpose in mental health including forensic mental health units • follow up with DHBs to document plans to remediate any significant issues identified as part of the condition and clinical facility fitness-for-purpose assessments • deliver a second report in the series ‘a national asset management plan for the health sector’ in 2022 with scope dependant on resources. This will be progressed in the context of work across the Health Infrastructure Unit to: • develop national service design and facility standards, settings, frameworks and guidance for capital planning • develop a sector-wide capital investment framework and plan • incorporate more emphasis on health equity and sustainability in asset management practice, including establish a sustainability work programme and reduce greenhouse gas emissions. 69 This list and priorities will be updated once the overall work programme has been completed and aligned with available resourcing. 70 THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS References Bjorberg S, Verweij M. 2009. Chapter 8: Lifecycle economics: cost, functionality and adaptability. In B Rechel, S Wright, N Edwards, B Dowdeswell, M McKee (eds), Investing in hospitals of the future (pp 145–66). London: European Observatory on Health Systems and Policies. Cabinet Office. 2015. CO (15) 5: Investment management and asset performance in the state services. Wellington: New Zealand Government. Cabinet Office. 2019. CO (19) 6: Investment management and asset performance in the state services. Wellington: New Zealand Government. Center for Health Design. 2015. A guide to clinic design post-occupancy evaluation toolkit. Concord, CA: Center for Health Design. Deloitte. 2015. Independent review of New Zealand’s electronic health records strategy. Wellington: Ministry of Health. Fronczek-Munter, A. 2013. Evaluation methods for hospital facilities. International Journal of Facilities Management (Special Issue): 215–26. Health and Disability System Review. 2019. Health and disability system review: Interim report: Hauora manaaki ki Aotearoa whānui: Pūrongo mō tēnei wā. URL: www.systemreview.health.govt.nz/interim-report (accessed October 2019). Marriot N, Mellett H, Macniven L. 2011. Loose coupling in asset management systems in the NHS. Management Accounting Research 22: 198–208. Minister for Building and Construction 2018. More certainty in construction sector smooths boom and bust cycle. URL: https://www.beehive.govt.nz/minister/honjenny-salesa?page=1 (accessed 12 June 2019). Minister of Health. 2016. New Zealand health strategy: Future direction. Wellington: Ministry of Health. Minister of Health. 2018. Fixing our hospitals. URL: https://www.beehive.govt.nz/release/fixing-our-hospitals (accessed 10 June 2019). Morrison Low. 2018. National asset register: Feasibility report. Wellington: Ministry of Health. National Health Board. 2011. Capital assessment guidelines. Wellington: National Health Board. Office of the Auditor-General. 2016. District health boards’ response to asset management requirements since 2009. Wellington: Office of the Auditor-General. Treasury. 2017. District health board financial performance to 2016 and 2017 plans. Wellington: New Zealand Government. 71 Appendix 1 DHB abbreviations 72 ADHB Auckland DHB BOPDHB Bay of Plenty DHB CCDHB Capital & Coast DHB CDHB Canterbury DHB CMDHB Counties Manukau DHB HBDHB Hawke’s Bay DHB HVDHB Hutt Valley DHB LDHB Lakes DHB MCDHB MidCentral DHB NDHB Northland DHB NMDHB Nelson Marlborough DHB SCDHB South Canterbury DHB SDHB Southern DHB TaiDHB Tairāwhiti DHB TarDHB Taranaki DHB WkDHB Waikato DHB WrDHB Wairarapa DHB WtDHB Waitematā DHB WCDHB West Coast DHB WDHB Whanganui DHB THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS Appendix 2 Scope, data confidence and reliability Buildings and infrastructure Table 15 shows the data confidence framework, from the International Infrastructure Management Manual, used to determine the confidence in the asset data used in the assessments for buildings and infrastructure. Table 15: Confidence grades for 2019 sources of assessment data Confidence Grade Meaning Highly Reliable Data based on sound records, procedure, investigations and analysis, documented properly and recognised as the best method of assessment. Reliable Data based on sound records, procedures, investigations and analysis, documented properly but has minor shortcomings; for example, the data is old, some documentation is missing, and reliance is placed on unconfirmed reports or some extrapolation. Uncertain Data based on sound records, procedures, investigations and analysis that is incomplete or unsupported, or extrapolated from a limited sample for which grade highly reliable or reliable data is available. Very Uncertain Data based on unconfirmed verbal reports and/or cursory inspection and analysis. Table 16 applies the confidence grades from Table 15 to the assets assessed to show the reliability of assessment data for each asset type. Table 16: Reliability of data for building and infrastructure assessments Asset Type Highly Reliable Reliable Uncertain Very Uncertain Critical older buildings, expert assessors Other buildings, DHB self-assessed Sitewide infrastructure – 31 main hospital sites Seismic restraint, passive fire, asbestos Structural integrity %NBS (earthquake) Structural resilience (earthquake) 73 Table 17 shows the percentage of completeness of the datasets used to assess each asset type in the 2018–19 assessments. Table 17: Data completeness for building and infrastructure assessments Asset Type 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Critical older buildings, expert assessors Other buildings, DHB self-assessed Sitewide infrastructure – 31 main hospital sites Seismic restraint, passive fire, asbestos Structural integrity %NBS (earthquake) Structural resilience (earthquake) Table 18 shows for building and infrastructure assets: whether there was a professional or DHB self-assessment, the focus of sampling for assets and components, and aspects that were out-of-scope. 74 THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS Table 18: Scope of 2019 building and infrastructure assessments Asset type & action Assessment type Sample focus Component focus Building condition 166 professional Critical buildings at Condition at main assessments main hospital component level for: campuses pre-2000 - building fabric build mechanical and electrical equipment Building operability: Out of scope Detailed rating of individual buildings or plant items - seismic restraint passive fire separation, presence of asbestos Building condition 993 DHB selfassessments Non-critical buildings at main hospitals pre-2000 build Condition at main component level for: - building fabric mechanical and electrical equipment Building operability: - seismic restraint passive fire separation presence of asbestos Infrastructure condition Professional assessments Sitewide reticulated Mechanical, infrastructure at 31 plumbing, heating, main campuses air conditioning Detailed rating of individual building or plant items (Some DHBs have this detail and used it to inform their ratings) Dunedin (due to rebuild plan) and Whakatāne (due to recent work and a minor campus) Electrical power, lighting, fire systems Dunedin (due to rebuild plan) and Whakatāne (due to recent work and a minor campus) Building structural integrity From DHB’s All buildings initial and detailed seismic assessments Structural rating %NBS No additional seismic assessments were commissioned Building seismic resilience Professional assessments of 34 properties Standardised reinterpretation of initial and detailed seismic assessments No additional seismic assessments were commissioned Buildings with suitable seismic assessments completed 75 Clinical facility fitness-for-purpose Table 19: Completeness of datasets for 2019 CFFFP assessments Asset Type 0% 10% 20% 30% 40% 50% 60% Acute mental health units Forensic mental health Inpatient units, sample of 20 Intensive care, coronary care and neonatal units Operating theatres – general & specialist suites Emergency departments Radiology departments Outpatient departments Therapies departments Pharmacy Laboratories 76 THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS 70% 80% 90% 100% Appendix 3 CFFFP gross floor areas The Australasian Health Facility Guidelines (AHFG) are intended to support designs for new clinical facilities in Australasia. The AHFG was used to inform assessments of the size of each clinical facility. First, a schedule of accommodation was created for each type of facility, and to support comparison, a gross floor area (GFA) per bed (or operating room) was calculated. Next, a ratio was calculated between each facility’s actual gross floor area per bed (or operating room) and the AHFG benchmark area per bed (or operating room). Older units can be expected to perform poorly when assessed in relation to these AHFG benchmarks. Tables 18-22 below shows for each facility assessed in Section 4: the DHB, location, actual gross floor area, number of beds (or operating rooms), GFA per bed (or operating room), and the ratio of the actual GFA to the AHFG benchmark. Table 20: Gross floor area analysis for emergency departments DHB Location Actual GFA No. of beds GFA / bed %AHFG benchmark@ m2 50 m2/bed 34 13 36 24 30 11 34 51 12 79 6 19 32 32 42 43 44 46 52 54 57 91 38% m2 NDHB Whangarei 638 SCDHB Timaru 418 MCDHB Palmerston North 1162 TarDHB Taranaki Base 1019 HBDHB Hawkes Bay 1296 TaiDHB Gisborne 481 LDHB Rotorua 1560 WkDHB Hamilton 2659 NMDHB Wairau CMDHB Middlemore CCDHB Kenepuru A&M17 17 646 4470 545 64% 65% 85% 86% 87% 92% 104% 108% 113% 182% Kenepuru is an accident and emergency service, rather than an emergency department. 77 Table 21: Gross floor area analysis for intensive care units DHB Location Actual GFA m2 SCDHB Timaru 365 TaiDHB Gisborne 378 MCDHB Palmerston North 467 NDHB Whangarei 605 HBDHB Hawkes Bay 717 WtDHB North Shore 966 TarDHB Taranaki 934 ADHB Auckland Starship Children’s 1458 WkDHB Waikato 1319 CMDHB Middlemore 2537 No. of beds GFA / bed 8 8 8 10 11 14 16 22 16 25 46 %AHFG benchmark @85 m2/bed for units < 15b @70 m2/bed for units >15b 54% 47 56% 58 69% 61 71% 65 77% 69 81% 58 83% 66 95% 82 118% 101 145% m2 Table 22: Gross floor area analysis for operating theatres DHB 78 Location Actual GFA m2 ADHB Auckland Starship Children’s 1499 ADHB Greenlane 1926 NMDHB Nelson 1507 TaiDHB Gisborne 1040 CMDHB Manukau SuperClinic 3184 HBDHB Hawkes Bay 2208 LDHB Rotorua 1672 CDHB Christchurch 3134 MCDHB Palmerston North 2234 SCDHB Timaru 1633 NDHB Whangarei 1965 CCDHB Kenepuru 1333 NMDHB Wairau 1716 WkDHB Waikato 8368 CDHB Burwood 1400 No. of operating rooms 7 8 6 4 12 8 6 11 5 7 6 4 5 24 4 THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS bed m2 GFA / %AHFG benchmark@ 214 76% 241 86% 251 90% 260 93% 265 95% 276 99% 279 100% 285 102% 319 114% 327 117% 328 117% 333 119% 343 123% 349 125% 350 125% 280 m2/ OR Table 23: Gross floor area analysis for inpatient units DHB Location Actual GFA m2 HBDHB HBDHB Hastings WA3 466 WkDHB Hamilton WM2 615 BOPDHB Tauranga W2A 548 MCDHB Palmerston North W24B 864 NDHB Whāngārei Children’s W2 815 CDHB Christchurch W19 688 HBDHB Hastings WB2 755 CMDHB Middlemore W23 785 WDHB Whanganui W2A 1007 ADHB Starship Children’s W24 676 TaiDHB Gisborne W5 710 NMDHB Nelson W9 822 GSG18 916 HVDHB Hutt NDHB Whangarei W2 Stroke ADHB Auckland City B9 1110 ADHB Greenlane Day Stay 1222 CMDHB Otara Spinal Unit WkDHB Hamilton W3 1213 CCDHB Kenepuru W7 1015 HVDHB Hutt OPRS19 18 GSG = general surgery and gynaecology 19 OPRS = older persons and rehabilitation service 815 890 2679 No. of beds GFA / bed 18 23 25 27 27 28 28 28 29 29 30 30 34 34 41 42 45 49 51 62 26 27 22 32 30 25 27 28 35 23 24 27 27 24 27 29 20 25 20 43 %AHFG benchmark @ 36 m2/bed 50% 63% 69% 75% 75% 76% 78% 78% 80% 82% 82% 85% 94% 94% 114% 117% 124% 135% 141% 173% 79 Table 24: Gross floor area analysis for mental health units DHB Actual GFA Location m2 CDHB Hillmorton Te Awakura South 617 SDHB Wakari Helensburgh W11 793 WtDHB North Shore Geriatric WkDHB Waikato Henry Bennett W35, W36 SCDHB Timaru Kensington 647 LDHB Rotorua Acute Psychiatric 786 WtDHB Waitakere Waiatarua 2385 CDHB Hillmorton Aroha Pai MCDHB Palmerston North W21 1631 SDHB Wakari W9B 1025 CCDHB Kenepuru Psychogeriatric 1133 HVDHB Hutt Te Whare Ahurua 1712 ADHB Auckland Te Whetu Tawera 4462 SDHB Southland Hospital 1544 NMDHB Nelson Waahi Oranga 2069 CMDHB Otara Tamaki Oranga 1516 TarDHB Taranaki Te Puna Waio 1764 BOPDHB Tauranga Te Whare Maiangiangi 1900 CDHB Hillmorton Tu Puna 1230 CMDHB Middlemore Tiaho Mai 3316 TairDHB Gisborne Psychiatric W11 958 WCDHB Greymouth 863 ADHB Auckland Pt Chevalier Buchanan 1817 WDHB Whanganui Te Awhina 1770 20 80 954 1746 PSAID20 914 No. of beds GFA / bed %AHFG benchmark m2 @ 80 m2/bed 16 16 19 33 12 14 40 15 24 15 16 24 62 21 28 20 23 24 15 38 8 7 14 12 39 48% 50 62% 50 63% 53 66% 54 67% 56 70% 60 75% 61 76% 68 85% 68 85% 71 89% 71 89% 72 90% 74 92% 74 92% 76 95% 77 96% 79 99% 82 103% 87 109% 120 150% 123 154% 130 162% 148 184% PSAID = Psychiatric service for adults with intellectual disability THE NATIONAL ASSET MANAGEMENT PROGRAMME FOR DISTRICT HEALTH BOARDS Appendix 4 Expert assessments for infrastructure This material is set out in a separate companion document. 81 MINISTRYOF HEALTH