Distribution Nelson Bays
Board Members: . John Hunter (Chair) . Pat Curry . Philip Chapman Primary Health . Sarah Green . Stuart Hebberd . Helen Kingston . Lisa Lawrence AGENDA . Sue Stubbs
Management: . Angela Francis, CE . Emily-Rose, EA/Board Secretary . Karen Winton, Acting GM Health Services . Linzi Birmingham, GM Golden Bay Board Community Health . Trudi Price, HR/Support Services Manager . Wolfgang Kloepfer, Finance Manager Open Public: . Hard copies (3) . Open Agenda Distribution List (e) . Website Date: 1 June 2017
Time: 2.00pm Contact Details Board Secretary: Emily-Rose Richards Place: Meeting Room 2 Tel: 03 543 7850 Nelson Bays Primary Health 281 Queen Street Richmond
Next Meeting Date: Thursday 6 July 2017 Nelson Bays Primary Health
Board Meeting 2.00pm Thursday 1 June 2017 Open
Agenda
1.45 – 2.00pm: Te Reo Training held for Board Members 2.00 – 2.10pm: Public Forum Page 1.0 Welcome/Karakia – John Hunter 2.0 Apologies: Stuart Hebberd 3.0 Register of Interests 3.1 Amendment to the Register of Interests 3 For review 3.2 Declaration of Conflicts in Relation to Today’s Business 4.0 Confirmation of Agenda For review 5.0 Minutes of 4 May 2017 5.1 Confirmation of Minutes 4 For approval 5.2 Matters Arising (and not for discussion in 5.3) 5.3 Discussion of Action Points 7 For review 6.0 Environmental Scan Discussion 7.0 Reports 7.1 Chief Executive’s Report – Open Section 8 For information 7.2 GM Health Services Operational Report 23 For information 7.3 Health and Safety Report 26 For information 8.0 Policies for Approval 28 For approval • Confidentiality Policy 30 For approval • Privacy Policy 34 For approval • Deputy Chairperson Selection Policy 41 For approval • Independent Chairperson Selection Policy 43 For approval • Subcommittee Selection Policy 45 For approval • Fixed Asset Management Policy 47 For approval 9.0 Position Descriptions for Approval 56 For approval • Position Descriptions: Independent Board Chairman 57 For approval • Position Description: Trustee 59 For approval 10.0 Board Work Programme 61 For information 11.0 General Business Discussion
Next Meeting: Thursday 6 July 2017 Register of Interests – Board | as at 4 May 2017
Possible Future Name Existing – Health Interest Relates To Existing – Other (Role) Conflicts Chair • PHO Alliance Executive • PHO • Ara Institute of Canterbury – (Director • None notified John Hunter since April 2011) • PHO Alliance Member • Powerhouse Ventures Ltd – Director
Helen Kingston • Abbeyfield Golden Bay Inc Medical Adviser • Incorporated Society providing accommodation • None declared • Non- and Committee Member for elderly Governmental Provider Lisa Lawrence • Member of the Order of St John • Motueka Family Service Centre • None notified • Motueka Family Service Centre • Have a provider contract with NBPH (Kaiwhakahaere) • Motueka Family Service Centre • Location of a lactation clinic for Motueka area • Motueka Health Alliance • Primary Health Services in Motueka • PHARMAC Community Advisory Committee • Member Pat Curry • Director Accuro Private Health Insurance • None declared • None notified
Philip Chapman • Employed by Nelson Public Health • Men’s health; positive fathering research; improve • Whakatu Boxing Trust • Potential • Manager – Men’s Centre (Male Room) access to family health services for fathers, men Community • National Chairman of Male Survivors Of & boys; Initiative Sexual Abuse A.N.Z • The Male Room receives money from the NBPH Funding Primary Mental Health Initiative. Sarah Green • Tasman Medical Centre • Employee • None declared • None notified • Nursing leadership • Nursing • Clinical Governance Committee • Member • NZNO College of Primary Nurses • Member • NZNO College of Respiratory Nurses • Member Stuart Hebberd • None declared • None declared • None declared • None notified Sue Stubbs • Tima Health • General practice owner with PHO contract • None declared • None notified • Nelson Bays General Practice Limited • Shareholder • ACC • Nelson Branch Medical Advisor CE • Institute of Directors, NZ • Member • None declared • None notified Angela Francis • Australasian College of Health Service • Fellow Management • Medical & Injury Centre • Director • Health Systems Solutions • Director • ToSHA • Rotating Chair
3 Nelson Bays Primary Health Board Meeting
Minutes of meeting held at 2.00pm on Thursday 4 May 2017 at Nelson Bays Primary Health, 281 Queen Street, Richmond
Open
PRESENT: John Hunter (Chair), Pat Curry (Deputy Chair), Helen Kingston, Lisa Lawrence, Philip Chapman, Sarah Green, Stuart Hebberd, Sue Stubbs.
IN ATTENDANCE: Angela Francis, Chief Executive; Emily-Rose Richards, Board Secretary; Karen Winton, Acting GM Health Services; Linzi Birmingham, GM Golden Bay Community Health (GBCH); Trudi Price, HR/Support Services Manager; Wolfgang Kloepfer, Finance Manager.
Public: (2) Lew Solomon and Dr Doug Smith
Public Forum
Mr Solomon informed the Board on his interest in Mental Health and discussed the research papers by Jonathon Schaefer and others on “Suicide Facts – Deaths and Intentional Self-Harm Hospitalisations” – MoH – Nov 2016. The paper shows that while Nelson Marlborough is below the New Zealand average in suicide deaths, it is well above average in hospitalisation owing to intentional self-harm. It also shows that while New Zealand is about average in the OECD for rate of suicide, it is very much above the OECD rate in youth suicide.
J Schaefer - J Schaefer - Is MOH - Suicide and Enduring Mental He“abnormal psycholo Self Harm.pdf
Dr Smith introduced himself to the Board, being a GP, with specialisation, seeking employment in the area.
1.0 Welcome/Karakia – Sarah Green
2.0 Apologies: Alistair Sowman, Chairman of Marlborough Primary Health.
3.0 Register of Interests
3.1 Amendment to the Register of Interests
Remove for Mr Chapman: • Chair of Waimea “Men’s Shed”
Remove for Ms Curry: • Board of Trustees on Abbeyfield Nelson Inc.
TO BE CONFIRMED 4 3.2 Declaration of Conflicts in Relation to Today’s Business
There were none.
4.0 Confirmation of Agenda
The agenda was confirmed.
5.0 Confirmation of Minutes of 2 March 2017
The minutes of 2 March 2017 were confirmed as a true and accurate record. Stubbs/Curry
5.1 Matters Arising
There were none.
5.2 Action Points
Some matters for consideration this month had been dealt with, formed part of today’s agenda or were discussed as follows:
A53 Discussions with Pharmacy Guild. A meeting was held between the Chief Executive and Jo Mickleson on 8 March 2017 who will contact the Pharmacy Guild Chief Executive to discuss local initiatives. Completed.
A59 Hon Annette King report. Completed.
A61 Update on interpreters service. Ms Winton attended a meeting at Nelson Marlborough Health (NMH) with the GM Maori Health to discuss the interpreters service. A follow up meeting is being held with Red Cross to see how there can be one organisation looking after the service. An update will be provided to the Board when information is to hand. Ongoing.
A62 Board Strategic Planning Day agenda. Completed.
A63 Doodle poll for Board Strategic Planning Day. Completed.
6.0 Environmental Scan
Mr Chapman noted he has been competing surveys from ACC, Ministry of Health and Parliament on family violence. Noting it is a government initiative to look at family violence. Ms Winton noted the government has also provided more funding to Family Start. Mr Hunter asked if there is a role for NBPH to help our population with family violence and the possibility of accessing the latest funding initiative announced by the Government? Ms Green noted we could be starting the conversation on NBPH forms asking along the lines of ‘is the patient safe at home?’ The Board will discuss further at the Board Strategic Planning Day on 8 May 2017.
Ms Francis informed the Board on the following: • Ministry for Vulnerable Children established • NMH have appointed a Consumer Council
7.0 Reports
7.1 Chief Executive’s Report – Open Section
Report taken as read. TO BE CONFIRMED 5 Ms Francis noted NBPH is tracking very well to budget and predicting a good surplus for year- end.
The Board held a discussion about the population who are unenrolled in a PHO in the top of the south to see how NBH can enrol the 3% of the population who are not enrolled. The requirements for enrolling in a General Practice were discussed and it was decided for a discussion on simplifying the requirements for registration, by linking to registration information already held by WINZ, to be taken to the Primary Health Alliance. Ms Winton was asked to write a one-pager on simplifying the requirements (including identification proof) for new patients enrolling in a General Practice, and send to Mr Hunter (cc Ms Lawrence), to then discuss with the Primary Health Alliance. A64
7.2 General Manager Health Services Operational Report – Open
Report taken as read.
Ms Winton advised that the ACC Falls Prevention Community Strength and Balance Programme contract has been received and signed.
The Brief Intervention Service waiting list is down to 2 weeks and the waiting time for the Primary Mental Health Initiative is 1-2 weeks. NMH funded NBPH $170k for 6 months to increase the primary mental health service, while they undertake a full service review. Management have had involvement in the re-design process and are awaiting the outcome for the mental health service in the future.
7.3 Health and Safety Update Report
Report taken as read.
Mr Hunter asked if Management are using the ‘near miss’ data at GBCH to prevent future recurrences? Ms Price informed the Board that the data is reviewed at the Health and Safety Committee meetings.
8.0 Board Work Programme
The Board Work Programme was received.
The Board asked for the Board meeting and Strategic Planning Day to be held on consecutive days, from 2018 onwards.
9.0 General Business
There was none.
The meeting closed at 2.57pm.
Next Meeting: Thursday 1 June 2017
TO BE CONFIRMED 6 OPEN Action List v 23 May 2017
Meeting Action Action Bring up Who Status date number Mar 17 A61 A follow up meeting is being held with Red Cross regarding June 17 GM HS Ongoing the interpreter service to see how there can be one organisation looking after the service. An update will be provided to the Board when information is to hand.
May 17 A64 Ms Winton was asked to write a one-pager on reducing the June 17 GM HS Refer to requirements (including identification proof) for new agenda item patients enrolling in a General Practice, and send to Mr 4.4.1 Hunter (cc Ms Lawrence), to then discuss with the Primary (closed Health Alliance. agenda)
7 To Nelson Bays Primary Health Board From Angela Francis, Chief Executive Meeting date 1 June 2017 Subject Chief Executive’s Report – Open Section
For approval For action For information √
1. PURPOSE
To provide the Board with an update of the organisation’s progress against strategy, risk and budget. Where appropriate, fuller details are provided in the Closed Agenda.
2. OVERVIEW
Business as usual continues: • Risk identification and mitigation. Refer Closed Agenda – Risk Register • Staffing levels – Nelson Bays Primary Health (NBPH) staffing levels remain constant. Refer Closed Agenda for attrition rates • Financial forecast – NBPH continues to track well against budget forecasting a surplus year-end. Refer to the Financial Report in the Closed Agenda for further details o Budget for 2017/18 was endorsed by the Board on 4 May 2017 • Progress against strategy continues as articulated through annual operational plan deliverables with new strategic priorities identified and confirmed at the Board Strategic Planning Day on 8 May 2017. A revised approach has been developed with additional reporting framework embedded. Refer to agenda item 3.3 (Strategic Initiatives) in the closed agenda.
3. MEDIA AND GOOD NEWS STORIES
3.1 Nelson Bays Primary Health Media Coverage
New Regional Director of Primary Health Nursing An article in the Nelson Mail on 5 May 2017, provided coverage on the new Regional of Director of Primary Health Nursing for NBPH and Marlborough Primary Health. Nurses will be better supported following the creation of a new role that will strengthen services across Nelson and Marlborough. Refer to Appendix 1 for the Regional Primary Health Nursing article in The Nelson Mail on 5 May 2017. A link to a Stuff article follows: http://www.stuff.co.nz/national/health/92161064/new-regional-director-of- nursing-provides-strategic-vision-across-top-of-the-south
4. CORPORATE SERVICES UPDATE
Information Systems The formal requisition forms were completed and submitted last month to Chorus, to enable installation of separate broadband for Collingwood Clinic. This has struck delays in implementation. Chorus advised that trenching and ducting of a separate cable would be required by their separate rural work team, unless completed by an alternative rural contractor both options requiring additional investment and time delays. Timelines and costing details of these options are being sought, with the Chorus Account
8 Liaison Manager being informed of our discontent with the late advice, time delays and additional costings experienced. The alternative solution is also being scoped, utilising Spark 4G wireless connections now available in the region; recent changes in plan options increase potential affordability of this option. Current scoping will be complete and a decision made in May 2017 to progress and resolve this outstanding issue.
Other projects continue to progress as scheduled. This includes the IT infrastructure tasks, remote desktop upgrades, NBPH Website Review and preparation for a new server installation at GBCH scheduled for June 2017.
Human Resources The Stakeholder surveys were presented during the Governance and Remuneration Committee meeting on 10 April 2017 as scheduled.
The Multi-Union Collective Agreement (MUCA) was received for countersignature by NBPH on 12 May 2017. Implementation plans to enact this agreement are now being scheduled against timelines to enable completion prior to end of June 2017, in line with the current financial year.
5. HEALTH SERVICES UPDATE
Health Services are tracking well against contractual and financial targets. Refer to agenda item 7.2 in the open agenda and agenda item 4.4 in the closed agenda.
6. GOLDEN BAY COMMUNITY HEALTH UPDATE
GBCH continues to perform in all areas. Refer to agenda item 4.1 in the closed agenda for further detail.
7. LOCAL PLATFORM
7.1 Nelson Marlborough Health (NMH)
NMH are awaiting their funding envelope to be confirmed by the Ministry of Health, due end of May 2017.
NMH is currently planning a series of reviews in specific service areas, some of which interface with primary care. These include: • Mental Health • District Nursing • Palliative Care
Top of the South Health Alliance (ToSHA) ToSHA including NBPH are undertaking a roadshow to update community and other stakeholders on the progress made towards the Primary and Community Strategy. Refer to agenda item 4.5.1 in the closed agenda for the community meetings dates/venues.
8. NATIONAL FORUMS
Primary Health Alliance For updates on the PHO Alliance and PSAAP, refer to agenda item 4.5 in the Closed Agenda.
9 9. CORRESPONDENCE
St John Funding Announcement Correspondence from St John was received regarding the funding boost they have received from the Government. St John will receive more than $100m in the budget for 2017/18 to provide double crewing of all emergency ambulance responses over the next four years. Refer to Appendix 2 for the correspondence from St John regarding the funding boost they have received from the Government.
Cyber Security Attack Correspondence from Health Systems Solutions (HSS) and Patients First was received regarding the actions they have undertaken from the Worldwide Cyber Security Attack. NBPH submitted an update to NMH regarding the status of NBPH. Refer to Appendix 3 for the NBPH status update to NMH and correspondence from HSS and Patients First regarding the actions undertaken from the Worldwide Cyber Security Attack.
10. RECOMMENDATION
It is recommended that: • The Board receives the report.
Appendices: 1. New Regional Director of Primary Health Nursing article in The Nelson Mail 2. Correspondence from St John regarding the funding boost they have received from the Government 3. NBPH status update to NMH and correspondence from HSS and Patients First regarding the actions undertaken from the Worldwide Cyber Security Attack
10 APPENDIX 1
New regional director of nursing provides strategic vision across top of the south
NELSON MAIL, SAMANTHA GEE – 5 MAY 2017
MARTIN DE RUYTER Christine Andrews Regional Director of Nursing for Primary Health.
Nurses will be better supported following the creation of a new role that will strengthen services across Nelson and Marlborough.
Christine Andrews has been appointed the new regional director of primary health nursing. She said the new role would provide strong leadership for nurses across the top of the south.
Nurses were the "glue in the health system" and the role would enable her to be a voice for nurses and the opportunity to have a strategic view across the industry.
The role had been developed between Nelson Bays Primary Health and Kimi Hauora Wairau – Marlborough's primary health organisation.
"We are one big family of nurses really, we ought to be on the same page doing the same things."
Andrews said there had been a shift in thinking that was reflected in the Nelson Marlborough Primary and Community Care Strategy.
"That is looking at supporting people closer to home and that is what nurses do, getting people well, preventing disease, giving good advice and health promotion, those are key nursing roles."
The health system was becoming increasingly complex and Andrews said her role involved helping nurses to navigate it.
She worked with around 120 nurses in Marlborough and there were 110 practice nurses in Nelson and at least a hundred more working in the community.
11 "They have quite a variety of roles but they have the same needs often for workforce, for training, for education opportunities and professional development."
Andrews is based in Marlborough where she worked for Kimi Hauora Wairau in a nursing leadership role. Before that, she spent 12 years as a senior policy analyst with the Ministry of Health. She had worked in a variety of nursing roles in primary care, including in paediatrics, community health and in general practice as well as at Plunket.
Nelson Bays Primary Health chief executive Angela Francis said the innovative new role would provide leadership across the top of the south.
"Given that nurses are a critical part of the workforce for the future, this appointment is timely and will enhance primary health nursing competencies, capability and leadership."
Kimi Hauora Wairau chief executive officer Beth Tester said she was delighted the PHOs could work together, which would strengthen nursing leadership across the region.
12 $33(1',;
15 May 2017
Angela Francis Chief Executive Officer Nelson Bays PHO
Dear Angela
You may have already heard yesterday’s announcement from the Government that more than $100 million will be included in this year’s budget to provide double crewing of all emergency ambulance responses over the next four years. The package also introduces a new sustainable funding model to increase St John’s baseline funding and to meet growing demand for ambulance services while addressing historic shortfalls. Ending single crewing is one of the most significant developments for our ambulance service ever, as it provides rural New Zealand with the same crewing levels as urban – a move that will save more lives and make it safer for our crews. We, of course, remain a charity and fundraising will continue to be part of our funding model – we’ll still need to raise more than 25% of our costs through donations, part charges and our commercial services. As we progressively move to end single crewing, we‘ll be working closely with local communities and we’ll keep you informed as we proceed. In the meantime, I’ve attached a copy of our media statement and accompanying fact sheet. If you have any questions, please do let me know – I’d be happy to discuss this significant development with you.
Kind regards
David Thomas General Manager South Island Region
Encl. Available attachments: x Media release x Map
13 MEDIA RELEASE EMBARGOED 14/5/17
St John welcomes Government funding boost
St John welcomes today’s news that more than $100 million will be included in this year’s budget to provide double crewing of all emergency ambulance responses over the next four years.
The package also introduces a new sustainable funding model to increase St John’s baseline funding and to meet growing demand for ambulance services while addressing historic shortfalls.
“Ending single crewing is one of the most significant developments in our ambulance service history,” says Chief Executive Peter Bradley. “We will be able to recruit 430 frontline jobs over four years and provide rural New Zealand with the same crewing levels as urban areas – a move that will save more lives and make it safer for our crews.”
“It will also give us the chance to promote from within and for a large number of our volunteer ambulance officers to become paid staff.”
Mr Bradley says the funding shows the Government’s commitment to ambulance services and recognises St John’s unique role in the New Zealand health system. “It means we’ll be in a better position to meet the growing demand for emergency primary care and community health services.”
While 375 of these roles will address single crewing, the remaining roles will be to deal with current and future increases in demand.
He says phasing out single-crewed emergency ambulances has been a priority for several years, the new funding model means St John can now plan for it with certainty.
“It will take time to gear up and implement, and the first step is reviewing each station across the country. One size does not fit all and we’ll be talking with local communities and our people on the ground to find the best approach in each area.”
One thing that won’t change is St John’s charity status and we will still need the support of New Zealanders through donations and part charges for ambulance services.
“We’ll still need to fund more than 25 per cent of our costs through donations and will continue to rely on the generosity of New Zealanders to maintain services and continue improving.”
-ENDS-
Page 1
14 ST JOHN – AMBULANCE - FACTS: x St John provides emergency ambulance services to nearly 90% of New Zealanders and covers 97% of the country’s geographical area x St John treated and/or transported 437,978 patients in the last financial year (end June 2016) x St John is made up of a mix of full-time paid employees and volunteer staff x St John has contracts with Ministry of Health and ACC who have been funding just under 70% of the operating costs for the ambulance service. The remaining 30% has been funded through emergency ambulance part charges, fundraising and revenue from commercial activities such as first aid training and medical alarms. St John’s fundraising and commercial activities also support the organisation’s charitable community programmes.
How St John is funded for Ambulance Services
Page 2
15 What’s Changing
Current State April 2017 Future State 2021 x 91% full crewing x 100% full crewing
x 35,849 single crewed responses x Zero single crewed responses (May 2016-April 2017) x 4,321 ambulance personnel (2,512 x 4,702* ambulance personnel (2,888 rural) rural) 1,168 paid ambulance staff 1,588 paid ambulance staff (up 420 3,153 ambulance volunteers plus 10 Clinical Control Centre staff, 430 up in total ) 3,114 ambulance volunteers
*NB 39 volunteer positions have been absorbed into full-time paid roles
For further information: Victoria Hawkins Noreen Hegarty St John Acting Head of St John Media & Public Relations Communications Advisor T 09 526 0528 ext 7877 T 09 526 0528 ext 8095 M 021 605 342 M 027 809 2058 E [email protected] E [email protected]
Questions and Answers Is this new funding enough to run an emergency ambulance service? Yes. The additional funding recognises the growing demand for our services and the challenges on staffing levels and resources. This investment addresses that and a number of issues, in particular a plan to introduce double crewing of emergency transporting ambulances across the whole country.
What are the advantages of double crewing? Double crewing will benefit patients, especially in rural areas where it means they will receive clinical care while they’re being driven to hospital – something that couldn’t be done with single crewing. It will make the job safer for our ambulance officers and help reduce fatigue, manual handling injuries and stress. New Zealand is the only first world ambulance service with single crewed ambulance responses – we currently do this 100 times a day across the country.
Are rural communities the biggest winners here? The additional government investment means that within four years, we’ll have the same level of service across all our areas. At the moment, most rural areas have some form of single crewed emergency transporting ambulances. We’ve wanted to address this for some time
Page 3
16 and the new funding means rural communities will soon have the same crewing levels available as in urban areas – a move that will improve safety and save lives.
Why is it taking four years to end single crewing? It’s important we get this right. The first step is reviewing our delivery model station by station and we’ll get input from our own people and local communities to make sure we get the best configuration of services in each area. It will also take time to recruit and train the extra 430 people and the staggered funding recognises that it will be a four year job.
Will St John still need to fundraise for donations? St John is and will always remain a charity. We’ve always worked closely with our communities and rely on the generosity of the public, both for donations and volunteers. The increased funding allows us to phase out single crewing and meet expected growth in demand, but St John will still need to fund about 25 per cent of its costs through donations, income from part charges and commercial activities like medical alarms to maintain current services. That figure’s currently about $54 million but will grow steadily as the service expands and in five years, we’ll be looking to raise close to $70 million a year above the funding from government to maintain services and programmes.
Will the number of ambulance stations change? There will be changes as we introduce 430 trained ambulance staff and replace single crewed ambulance responses with double crewed transporting responses. What that will look like is what we will be discussing with staff and local communities. We expect the number of stations to stay about the same and that’s part of the detail we’ll be working on next.
Why the reduction in volunteer numbers? We expect the number of volunteers to remain about the same though, on paper, some positions could be absorbed into the paid work force. It takes many volunteers to cover the equivalent of one full time ambulance officer. As we train and employ more permanent ambulance officers, we’ll need fewer volunteers to cover those roles. We hope many of our current volunteers will apply for those permanent paid roles and we’ll also need more than 1,400 volunteers to crew an increase in First Response Units.
Where will the extra ambulance officers be deployed? The location and the timing of the deployment is what we need to turn our attention to now. Initial panning suggests the district distribution shared on the next page in map diagram form. We’ll consult with staff and our communities to find the best fit and mix.
Page 4
17 Distribution of 430 additional ambulance staff over four years
Northland
Central East 46 (Bay of Plenty and Lakes) Auckland (Auckland, Counties Manukau and Waitemata) 65 45
Clinical Control Centre staff 10(Auckland)
Central West (Waikato78 and Taranaki) Central South (Mid Central, Hawkes Bay and69 Whanganui) Tasman (Nelson Marlborough and41 West Coast) Canterbury (Canterbury and South44 Canterbury)
Total Southland/Otago 430 32 Frontline staff
These numbers are indicative only. St John will consult internally and externally to find the best approach18 and fit for each community. St John does not operate emergency services in the Wellington/ Wairarapa area. APPENDIX 3
From: David Stichbury Sent: Monday, 15 May 2017 9:51 a.m. To: Kirsty Martin
Hi Kirsty
An update regarding the status of NBPH.
1. Infection Status:
No infections
2. Patching:
We are working closely with CCL to ensure we are fully compliant with up-to-date patches. Additional patching to ALL desktop PCs and laptops will take place today. Servers will also undergo further patching this evening to ensure they are fully compliant.
3. Key Mitigation Activities:
An email has been sent to all users over the weekend with key message regarding unexpected emails and the need for vigilance. This will be followed up today. We will be pushing the “If you didn’t expect it, reject it” campaign. NBPH has 15 minute backups of the MedTech database in Golden Bay, hourly replication backups of all file systems and key servers (Exchange, File Server, etc.) across Richmond and Golden Bay sites. NBPH has an active firewall (hardware) and up-to-date antivirus (software)
4. Service Impact:
There will be patching for all desktops today which may impact on productivity for 15 to 30 minutes Patching of servers this evening will impact on some users. They will be notified regarding this.
Regards
David
David Stichbury | IT and Communications Manager Tel: 03 543 7839 | Mob: 021 409 589 Email: [email protected] 281 Queen Street, Richmond. PO Box 1776, Nelson 7040 Ph 03 539 1170 www.nbph.org.nz
19 From: Kyle Forde [mailto:[email protected]] Sent: Sunday, 14 May 2017 8:37 p.m. To: Bill Eschenbach
Hi Team
Following the Cyber Attack over the weekend the following actions were taken:
1. HSS hosted Servers checked for up to date patches and internet security updates – All Passed 2. Karo hosted Servers checked for up to date patches and internet security updates – All Passed 3. CHCHPHO hosted Servers checked for up to date patches and internet security updates – All Passed 4. WellSouth on-premise Servers checked for up to date patches and internet security updates – All Passed
Where servers, laptops and desktops are managed onsite by your local third party provider we recommend you contact your provider asap to check these devices.
The Ministry of Health have requested all PHO’s report to them daily 10am and 4pm to report status of the below items.
Organisation: Date/time:
1. Infection Status: No Infections/Infections 2. Patching status (client and server OS): Complete/In progress 3. Key mitigation activities: Provide brief summary 4. Service impact: Provide brief summary of any service impact due to the response and mitigation activities
If you have any questions please feel free to call me directly.
Kind Regards.
Kyle Forde, Chief Information Officer, WellSouth
027 55 000 33 | 03 477 1163 | wellsouth.org.nz Level 1, 333 Princes St, PO Box 218, Dunedin 9054
20 From: Helmut Modlik [mailto:[email protected]] Sent: Saturday, 13 May 2017 1:42 p.m. To: Adrian Rasmussen
Hello everyone,
Worldwide health IT systems have been subject overnight to a cybersecurity attack as outlined in the following release:
“Today, widely reported in the media is a wide-scale cybersecurity attack that was first reported affecting the healthcare system in the UK. News outlets are reporting that the infection has spread to as many as 74 countries. Press accounts detail a ransomware attack that has been leveraged using a leaked National Security Agency (NSA) hacking tool. The New York Times reported, "The malware was circulated by email; targets were sent an encrypted, compressed file that, once loaded, allowed the ransomware to infiltrate its targets." The Guardian reports that countries are being hit with a "huge, fast-moving and
21 global ransomware attack that locks computers and demands the digital equivalent of $300, according to Kaspersky Lab, a Russian-based cybersecurity company."
The Ministry of Health and District Health Boards are working hard today to ensure appropriate measures are being taken to mitigate the risk of this attack on the New Zealand health sector. PHOs are asked to liaise as soon as possible with their member practices to (a) warn about the heightened risk of opening unsolicited emails and attachments, and (b) implement remedial measures e.g. patches to remove the malware risk involved.
Further information and/or updates will be provided by the Ministry and DHBs, and will be distributed as required. Lastly, please advise urgently if you become aware of any Practice that is affected by this cyber attack.
Regards
Helmut Modlik Chief Executive Officer m| 021 645 671 e | [email protected] w| www.patientsfirst.org.nz a | 50 Customhouse Quay, Level 4, PO BOX 10440 Wellington
22 To Nelson Bays Primary Health Board From Karen Winton, Acting GM Health Services Endorsed by Angela Francis, Chief Executive Meeting date 1 June 2017 Subject General Manager Health Services’ Operational Report – Open Section
For approval For action For information √
1. SERVICE OVERVIEW
The Health Services Division cost centres is tracking to budget with a surplus forecast for year-end.
System Level Measures (SLM) workshops continue to be held, in conjunction with Nelson Marlborough Health (NMH), to ensure NBPH is working together to achieve contributory measures with clear action plans across the sector.
NBPH has led the development of, and recently welcomed, the newly appointed Regional Director of Primary Health Nursing, who will be working across Nelson Marlborough primary care and will provide professional leadership for the nursing workforce.
The Health Services Team welcomes the newly appointed Primary Health Facilitator in June.
2. HEALTH PROMOTION
Falls Prevention ACC community-based Strength and Balance partnership agreement is currently in the implementation stage with this part being due for completion by the 30 June 2017.
The Fracture Liaison Service (FLS) requires funding from DHB to be provided to implement the osteoporosis/ falls/malnutrition screening tool. This has been raised at recent Falls Alliance meeting and formal written agreement is yet to be received. No further service improvements can be provided without this tool in place.
Green Prescription The Hip and Knee programme has delivered a further two clinics within the last month to address osteoarthritis self-management across our rural communities. There is a huge demand for this self- management course at this time but these programmes will reduce to funded target of one per month in the future.
The Quick Start programme has run two sessions and Kick Start have run three within the month. The referral target is reduced due to no referral links on current web-based forms. This is currently being investigated.
Community Nutrition The Toddler Better Health programme is currently in progress in Richmond. Clinics continue to be provided with 42 clients seen in the last month.
23 There is limited dietician services regionally to manage malnutrition issues. This is becoming more of a challenge with the aging population growth. This issue has been raised at the local Nelson Marlborough Falls Alliance Steering group.
Cardiac Rehabilitation NBPH are still awaiting results from the budget bid submitted to continue to provide this unique primary care service, these are not expected until May. One session has been delivered this month with 12 people attending.
Interpreter Services NMH have now agreed to work alongside Red Cross and Pacific Trust to sub-contract interpreter services to manage this service line. This will include Red Cross having responsibilities for training, all bookings and potentially financial responsibilities. A meeting to further discuss terms and which services are linked will be held shortly.
3. PRIMARY HEALTH
After Hours Telephone Nurse Triage A meeting was held in May to discuss this contract further and the outcome is there is expected to be no change to the current agreement with a further meeting to be held in approximately six months to look at potential future options between services.
Respiratory Service The Pulmonary Rehabilitation Service programme has completed its first full programme with excellent results and feedback from all participants involved. This programme will continue to be run by the Asthma Society via funding from NBPH and with the support of NBPH’s Respiratory Nurse.
NBPH’s Respiratory Nurse is currently supporting NMH to review the significant waitlist for Respiratory clients with an agreement on resourcing reached.
Smoking Cessation NBPH’s latest results are 89%, which is similar to last months results. NBPH are continuing to work with General Practices to ensure this issue is raised as a priority across their services and is currently recruiting for a new staff member who will focus on both Smoking Cessation and Respiratory Health.
National Enrolment Service (NES) This is now operative following the temporary shutdown by the MOH due to potential privacy concerns. All General Practices have been sent the required information to update their systems back online.
4. SPECIALIST SERVICES
Infectious Diseases NBPH’s Infectious Diseases Specialist is currently working with Dr Dave Dixon to combine hospital and community (Health Pathways) guidelines for improved consistency of approach. They are also investigating the potential use of a South Island wide smart phone app to support professionals in the future.
Telephone advice and face-to-face appointments are provided in an efficient timeframe. More virtual clinics are happening with positive feedback from clients.
24 Community Rheumatology Service This service has an overdue waitlist so NBPH’ is increasing clinics provided to redress this issue.
NMH have agreed to provide ongoing increased funding, with an expectation on increased targets and reporting arrangements requested.
5. MAORI HEALTH
Kaiatawhai Service Referrals remain steady with goods outcomes. Currently working on formal evaluations of this service.
Kaitakawaenga Luke Katu is providing Staff with weekly Māori language lessons. Four Treaty of Waitangi workshops and two Cultural awareness sessions have been held.
6. MENTAL HEALTH
Primary Mental Health Initiative (PMHI) and Brief Intervention Service (BIS) A Mental Health review has been held this month across all Non-Government Organisations by an independent panel, with an emphasis on identifying perceived gaps and opportunities for aligning service provision where this may improve outcomes for clients. A timeframe for the report from this has not been provided.
The current demand for services across PHMI and BIS remains high.
7. RECOMMENDATION
It is recommended that: • The Board receives the report.
25 To Nelson Bays Primary Health Board From Naomi Johnson, Lead Health and Safety Representative Endorsed by Angela Francis, Chief Executive Meeting date 1 June 2017 Subject Health and Safety Report
For approval For action For information √
1. OVERVIEW AND UPDATE
The following provides a high level update on Health and Safety for Nelson Bays Primary Health (NBPH). This report presents records from both Richmond and Golden Bay sites. This month there are no issues of concern to report.
2. INCIDENT AND HAZARD REPORTING
All incidents reported in April occurred at Golden Bay Community Health (GBCH). Three of these incidents were classified as Health and Safety incidents, relating to staff injury or were risks for increased staff stress due to staffing or resourcing issues. The following graph compares the incidents previously reported in February and March, as well as the newer incidents from April this year. No incidents were “serious harm”.
Table 1. Near Miss and Incident Records April 2017:
Incident Reporting: 1 February to 30 April 2017
12 10 8 6 4 2 0 GBCH - Staff GBCH - Richmond GBCH - Staff GBCH - Richmond GBCH - Staff GBCH - Richmond Patients Patients Patients February March April
Near-Miss: no harm Actual: no harm Actual: injury Serious Harm
3. OTHER HEALTH AND SAFETY ACTIVITIES
Stress in the Workplace It is difficult to identify stress in the workplace, as stress can be mediated by both workplace and personal factors. To guide the organisation in this the workplace monthly usage of the Employee Assistance
26 Programme (EAP) services is considered. EAP is a confidential service and the matters raised are not necessarily stress related. There has been no use of the EAP service in the past month.
Golden Bay Activities • Monthly meeting attended as scheduled • Four GBCH staff attended Coordinated Incident Management Training (CIMS 4) • 43 staff members completed their online and practical Fire Safety Training • Awaiting feedback from South Island Emergency Planning Coordinator on GBCH Emergency Plan
281 Queen Street Activities • Four Richmond NBPH staff attended Coordinated Incident Management Training (CIMS 4) • Regular input into staff newsletter • No new hazards, nor incidents to manage at this time.
4. RECOMMENDATION
It is recommended that: • The Board receives this report.
27 To Nelson Bays Primary Health Board From Emily-Rose Richards, Executive Assistant/Board Secretary Endorsed by Angela Francis, Chief Executive Meeting Date 1 June 2017 Subject Policies for Approval
For approval √ For action √ For information
1. PURPOSE
To provide the Board with updated policies, which require the Board’s approval.
2. SUMMARY OF POLICIES
At the Governance and Remuneration Committee meeting on 7 February 2017, the following policy amendments were agreed on:
Confidentiality Policy The following amendments were made to the Confidentiality Policy: • Include a paragraph on the obligations/consequences of not complying with the confidentiality policy, in terms of remedies under the employment agreement, common law and contracts • Mr Hunter to forward a confidentiality agreement to Ms Francis to use as Appendix 1
At the following Governance and Remuneration Committee meeting on 10 April 2017, the Confidentiality Policy was recommended to the Board for approval. Refer to Appendix 1 for the Confidentiality Policy.
Privacy Policy The following amendments were made to the Privacy Policy: • Amend section 5.3, rules 1 – 12: Rules to be simplified and referenced to Appendix 1 • Policy to be simplified • Change ‘Rule’ to read ‘Principle’ throughout the Policy • Amend page 2, section 2, last paragraph to read: ‘All NBPH employees are required to complete training in relation to the Privacy Act to understand their responsibilities, with refresher training to be completed every three years as a maximum. This training is to be recorded by the line manager in the employee files.’
At the following Governance and Remuneration Committee meeting on 10 April 2017, the Privacy Policy was recommended to the Board for approval. Refer to Appendix 2 for the Privacy Policy.
At the Governance and Remuneration Committee meeting on 10 April 2017, the following policy amendments were agreed on:
Deputy Chairperson Selection Policy The Deputy Chairperson Selection Policy was recommended to the Board for approval, subject to the following amendments being made: • Amend page 1, section 4, last bullet point to include at the end: ‘provided however, that the Chair retains the right to reject the candidate for good reason.’
28 Refer to Appendix 3 for the Deputy Chairperson Selection Policy.
Independent Chairperson Selection Policy The Independent Chairperson Selection Policy was recommended to the Board for approval, subject to the following amendments being made: • Amendments to page 2, section 5, paragraphs 5 – 8 to read: ‘Advertise in relevant print media, NBPH and DHB websites, NZ Institute of Directors and other avenues as appropriate.
The Selection Panel will review the interview questions, shortlist and interview candidates, and references of recommended candidates to be contacted. A search utilising media search will be undertaken.
The Board will meet with the recommended candidates prior to discussing appointment to determine the “fit” with the Board, the NBPH in general, our enrolled population, providers, community and iwi. There will also be a limited opportunity to pose any questions, however, this is considered a “meet and greet” rather than a second interview.
The Board will make the final selection. The appointee to be confirmed at the AGM (or by Special Resolution in the event of the Chairperson not seeing out their full term).’
Refer to Appendix 4 for the Independent Chairperson Selection Policy.
Subcommittee Selection Policy The Subcommittee Selection Policy was recommended to the Board for approval, subject to the following amendments being made: • Amend page 1, section 3, bullet point 4 to read: ‘There is the ability to have alternates/proxy at the meetings.’
Refer to Appendix 5 for the Subcommittee Selection Policy.
At the Audit and Financial Risk Committee meeting on 12 April 2017, the following policy amendments were agreed on:
Fixed Asset Management Policy The Fixed Asset Management Policy was recommended to the Board for approval, with no amendments made.
Refer to Appendix 6 for the Fixed Asset Management Policy.
3. RECOMMENDATION
It is recommended that the Board approves the: • Confidentiality Policy, Privacy Policy, Deputy Chairperson Selection Policy, Independent Chairperson Selection Policy, Subcommittee Selection Policy, and Fixed Asset Management Policy.
Appendices: 1. Confidentiality Policy 2. Privacy Policy 3. Deputy Chairperson Selection Policy 4. Independent Chairperson Selection Policy 5. Subcommittee Selection Policy 6. Fixed Asset Management Policy
29 APPENDIX 1
TITLE: Confidentiality Policy
1. Statement / Purpose
The purpose of this policy is to ensure Nelson Bays Primary Health (NBPH) Board Trustees, committee members, employees, volunteers, and the workers of organisations contracted to NBPH understand that information gained in the course of their involvement and activities with NBPH • Is confidential and • May not be disclosed outside of NBPH business without authorisation from the NBPH Board Chair or Chief Executive.
2. Scope
This policy applies to all NBPH Board Trustees, committee members, employees, volunteers, contracted organisations and their workers.
3. Details
3.1 All matters that are the subject of public excluded (closed) sessions of the Board are confidential until disclosed in an open session of the Board.
3.2 All matters that are before a Committee or task force of the Board are confidential unless they have been determined not to be confidential by the NBPH Committee Chair or Chief Executive.
3.3 All information that may be sighted or acquired during the course of work is confidential. This includes, but is not restricted to, information about: • NBPH’s funding, business practices and clients • Contractual relationships and information • Performance data • Confidential email and contact lists e.g. personal details of GPs, board members and employees • NBPH providers’ and its contracted providers’ business information including performance data/information • Medical practitioners and other health practitioners, including the number of consultations they undertake • Information about the patients of medical practitioners • Individual and collated clinical and/or service-based data • Aggregated and/or non-identifiable data about the organisation, membership, members and/or patients
3.4 The parties to confidential information gained during the course of their work and activities with NBPH must treat the information in absolute confidence and will not at any time attempt to use such information for: • Their personal gain or advantage
Nelson Bays Primary Health Organisation Policy: Confidentiality Policy Authorised by: Issue Date: February 2012 Review Date: May 2020 Version: 3 Page 1 of 4 NBPH Board Version Date: May 2017 30 • The personal gain or advantage of any person, partnership or corporation with whom the employee may become associated • The disadvantage of NBPH as an organisation • The disadvantage of any individual within NBPH.
Confidential information of any nature is not to be passed on to any external party without the prior permission of the NBPH Board Chair or Chief Executive. Breaches of this policy may be viewed as serious misconduct under the NBPH Code of Conduct and the consequences of not complying with this policy will be implemented according to this Code of Conduct.
4. Related Documents
a) Confidentiality Agreement Form (Appendix 1) b) NBPH Media Relations Policy c) NBPH Individual Employment Agreements d) NBPH Code of Conduct e) NBPH Contract for Services
5. References
• Privacy Act 1993 and Privacy Principles https://www.privacy.org.nz/news-and- publications/guidance-resources/information-privacy-principles/ • Health Information Privacy Code 1994 https://www.privacy.org.nz/assets/Files/Codes- of-Practice-materials/HIPC-1994-2008-revised-edition.pdf
Approved by: NBPH Board
Nelson Bays Primary Health Organisation Policy: Confidentiality Policy Authorised by: Issue Date: February 2012 Review Date: May 2020 Version: 3 Page 2 of 4 NBPH Board Version Date: May 2017 31 APPENDIX 1 – CONFIDENTIALITY AGREEMENT For completion by NBPH Trustees, Committee Members, Employees, Volunteers, Contractors and their Workers
Parties: Nelson Bays Primary Health (NBPH)
And (Full Name): ______
From (Name of Organisation): ______
Agreement to Comply with NBPH Policy on Confidentiality
In agreeing to comply with NBPH Policy on Confidentiality, you are agreeing to adhere to the Privacy Act 1993, Privacy Principles within the Act and the Health Information Privacy Code 1994.
The parties acknowledge that during the course of work on behalf of Nelson Bays Primary Health (NBPH), you may sight and/or will acquire confidential information. It is agreed that such confidential information includes that which may relate to, but is not restricted to: • NBPH’s funding, business practices and clients • Contractual relationships and information • Performance data • Confidential email and contact lists e.g. personal details of GPs, board members and employees • NBPH providers’ and its contracted providers’ business information including performance data/information • Medical practitioners and other health practitioners, including the number of consultations they undertake • Information about the patients of medical practitioners • Individual and collated clinical and/or service-based data • Aggregated and/or non-identifiable data about the organisation, membership, members and/or patients
The parties agree that you will at all times treat all information obtained during your duties in absolute confidence and will not at any time attempt to use such information for: • Your personal gain or advantage • The personal gain or advantage of any person, partnership or corporation with whom the employee may become associated • The disadvantage of Nelson Bays Primary Health as an organisation • The disadvantage of any individual within Nelson Bays Primary Health.
Confidential information of any nature is not to be passed on to any external party without the prior permission of the Nelson Bays Primary Health Board Chair or Chief Executive.
Signed: ______Date:
Relationship (please circle): Trustee / Committee Member / Employee / Volunteer / Contractor
On behalf of Nelson Bays Primary Health:
Nelson Bays Primary Health Organisation Policy: Confidentiality Policy Authorised by: Issue Date: February 2012 Review Date: May 2020 Version: 3 Page 3 of 4 NBPH Board Version Date: May 2017 32 Signed:
Name: ______Date:
Nelson Bays Primary Health Organisation Policy: Confidentiality Policy Authorised by: Issue Date: February 2012 Review Date: May 2020 Version: 3 Page 4 of 4 NBPH Board Version Date: May 2017 33 APPENDIX 2
TITLE: Privacy Policy
1. Statement / Purpose
To ensure that Nelson Bays Primary Health (NBPH) meets its duties and responsibilities with respect to the Privacy Act 1993 and the Health Information Privacy Code 1994.
2. Background
The Privacy Act establishes that information concerning an individual should be collected, stored, used and destroyed in a manner which ensures that the individual concerned (and in certain circumstances their relatives) are not either actually, or potentially harmed. Failure to comply with the 12 Information Privacy Principles in the Privacy Act can result in severe legal penalties for the individual and/or organisation breaching the principles.
The Health Information Privacy Code applies to all health agencies and individuals who use health information. The code does not apply to statistical or anonymous information which does not enable the identification of an individual. The Health Information Privacy Code does not supersede standards of ethical and professional conduct of health professions, but sets minimum standards with which all individuals and organisations have to comply.
All health agencies must have a recognised and authorised Privacy Officer.
3. Scope
The policy applies to all NBPH employees and volunteers, workers contracted to NBPH, and Board and Committee members as they carry out NBPH business.
4. Definitions
Not Applicable.
5. Details
1. NBPH Privacy Officer
The Privacy Officer is the Chief Executive, or a duly authorised representative.
The responsibilities of a Privacy Officer include: • Ensuring NBPH compliance with the provisions of the Privacy Act and Privacy Principles (Appendix 1) covering the collection, use, management and storage of personal information • Dealing with access and correction requests made to NBPH • Working with the Privacy Commissioner on any investigation into NBPH
Nelson Bays Primary Health Organisation Policy: Privacy Policy Authorised by: Issue Date: August 2013 Review Date: May 2020 Version: 3 Page 1 of 5 NBPH Board Version Date: May 2017
34 • Ensuring all employees are educated about the privacy implications of information handling practices • Through an annual audit, identifying any areas of the organisation that may be in breach of the Privacy Act or Health Information Privacy Code and if breaches are identified, ensuring remedial action is taken • Ensuring adequate resource allocation for health information security • Ensuring employees comply with security related policy • Ensuring all NBPH information collection, use and storage complies with the Health Information Privacy Code • Authorising access to health information for relevant employees.
2. Compliance and Training
All NBPH employees, workers contracted to NBPH, NBPH Board and Committee members are to comply with the Privacy Principles and Health Information Privacy Code requirements in all contacts with an employee’s personal information, patients and/or patient information, in all circumstances. Failure to comply may be viewed as serious misconduct as outlined in the NBPH Code of Conduct.
All NBPH employees are required to complete training in relation to the Privacy Act to understand their responsibilities, with refresher training to be completed every three years as a minimummaximum. This training is to be recorded by the line manager in the employee files.
3. Privacy Principles and Health Information
NBPH systems and processes must comply with the Privacy legislative and regulatory requirements.
The Health Information Privacy Code builds on Privacy Principles and applies them specifically to Health information. These Rules Principles from the Health Information Privacy Code are aligned with NBPH policy as detailed below.
The principles are as follows and may be found in Appendix 1: • Rule Principle 1 – Purpose of Collection of Health Information Formatted: Indent: Left: 0 cm, Hanging: 0.5 cm, Bulleted Most health information is collected in a situation of confidence and trust and the manner + Level: 1 + Aligned at: 0.63 cm + Indent at: 1.27 cm of collection should reflect that confidence and trust by: • Ensuring that health information is only collected from a person if it is for a lawful purpose connected with the function or activity of the health agency and is necessary for that purpose (e.g. care and treatment, administration, training and education, quality assurance). • Rule Principle 2 – Source of Health Information Formatted: Heading 1, Indent: Left: 0 cm, Hanging: 0.5 cm, Bulleted + Level: 1 + Aligned at: 0.63 cm + Indent at: Information shall be collected directly from the person concerned or from a person who 1.27 cm he/she authorises or who is their legal representative. • Rule Principle 3 – Collection of Health Information from Individual Formatted: Indent: Left: 0 cm, Hanging: 0.5 cm, Bulleted All reasonable steps must be taken to ensure the person knows: + Level: 1 + Aligned at: 0.63 cm + Indent at: 1.27 cm • That the information is being collected
Nelson Bays Primary Health Organisation Policy: Privacy Policy Authorised by: Issue Date: August 2013 Review Date: May 2020 Version: 3 Page 2 of 5 NBPH Board Version Date: May 2017
35 • The purpose for which the information is being collected • The intended recipients of the information • The name and address of the agency collecting and holding the information • The consequences to that individual and/or representative if all or any part of the requested is not provided (e.g. that failure to provide information for education and training purposes will not prejudice treatment) • The right of access to correct the health information. • Rule Principle 4 – Manner of Collection of Health Information Formatted: Indent: Left: 0 cm, Hanging: 0.5 cm, Bulleted Patient information shall not be collected by unlawful or unfair means or intrude to an + Level: 1 + Aligned at: 0.63 cm + Indent at: 1.27 cm unreasonable extent upon personal affairs of the individual concerned (sensitively taken history would not constitute ‘intrusion’; however, areas that the individual regards as intrusive should not be pursued). • Rule Principle 5 – Storage and Security of Health Information Formatted: Indent: Left: 0 cm, Hanging: 0.5 cm, Bulleted NBPH will ensure that patient information is protected against loss, access, use, + Level: 1 + Aligned at: 0.63 cm + Indent at: 1.27 cm modification or disclosure or misuse. All efforts are to be made to prevent unauthorised use or unauthorised disclosure of the information, such as: • Patients’ notes/records must not be taken from the places specified for their secure storage without prior authorisation from the Privacy Officer or delegate • Patients’ notes/records authorised to be taken off the premises must be kept secure during transportation (e.g. carried in a locked case) and remain inaccessible to others • No patient information is to be sent via unsecured email or posted via the internet • No patient files should be copied to local storage (“C drive”) of employee computers • All patient information should be stored on secure (“R drive”) or password protected sites on the NBPH server • Employees access to individual health information is determined and authorised by the Privacy Officer or delegate • All patient health information is transferred between NBPH and General Practice or authorised service provider via a secure method i.e. Health Link. • Rule Principle 6 – Access to Personal Health Information Formatted: Indent: Left: 0 cm, Hanging: 0.5 cm, Bulleted NBPH shall provide to the patient, on request, confirmation of whether or not NBPH holds + Level: 1 + Aligned at: 0.63 cm + Indent at: 1.27 cm information about them and also provide access to that information. • Rule Principle 7 – Correction of Health Information Formatted: Indent: Left: 0 cm, Hanging: 0.5 cm, Bulleted Individuals have the right to request correction of their health information. NBPH will + Level: 1 + Aligned at: 0.63 cm + Indent at: 1.27 cm consider any request to correct health information, and will make the changes. When a change is made, it will be noted by the person authorising the change. Where a request for correction is refused, the individual must be informed of the following: • Reasons for refusal • Supporting grounds for refusal • Right to request the attachment to the information of a statement provided by the individual of the correction sought • Right to complain to the Privacy Commissioner and to seek an investigation and review of the decision. • Rule Principle 8 – Accuracy of Health information to be Checked before Use Formatted: Indent: Left: 0 cm, Hanging: 0.5 cm, Bulleted NBPH is required to check the accuracy of health information before using it. The steps + Level: 1 + Aligned at: 0.63 cm + Indent at: 1.27 cm which it is reasonable to take will vary depending upon the proposed use. Rigorous checks will be appropriate if decisions based on health care entitlements are to be based on the information but if it is to be aggregated for statistical purposes, few or no checks may be
Nelson Bays Primary Health Organisation Policy: Privacy Policy Authorised by: Issue Date: August 2013 Review Date: May 2020 Version: 3 Page 3 of 5 NBPH Board Version Date: May 2017
36 needed, particularly if the checking process would unnecessarily intrude on the individual’s privacy. • Rule Principle 9 – Retention of Health Information Formatted: Indent: Left: 0 cm, Hanging: 0.5 cm, Bulleted Health information must be retained under the express requirements of certain + Level: 1 + Aligned at: 0.63 cm + Indent at: 1.27 cm enactments, such as: • The Health (Retention of Health Information) Regulations 1996 • Clause 58 of the Medicines Regulation 1984.
Generally the Health (Retention of Health Information) Regulations 1996 require health records to be retained by health agencies for 10 years. NBPH may lawfully retain records longer than this for the purposes of administration, monitoring, training and education. Where health information is stored for long periods, it is to be held in secure storage e.g. in a secure and locked filing cabinet or warehouse or off-line.
When disposing of information e.g. hard drives, flash drives etc, NBPH will dispose of information in a manner that preserves the privacy of the individual. For example: document destruction through e.g. Online Security Services (Iron Mountain); computer information to be destroyed through the appropriate secure means. • Rule Principle 10 – Limits on Use of Health Information Formatted: Indent: Left: 0 cm, Hanging: 0.5 cm, Bulleted NBPH will not use the health information for any other purpose unless NBPH believes that: + Level: 1 + Aligned at: 0.63 cm + Indent at: 1.27 cm • The disclosure of information is for one of the purposes in connection with which the information was obtained • The information is a publicly available publication • Use of the information is necessary to prevent or lessen a serious or imminent threat • The information is used or will be published in a form in which the individual concerned is not identifiable. • Rule Principle 11 – Limits on Disclosure of Health Information Formatted: Indent: Left: 0 cm, Hanging: 0.5 cm, Bulleted NBPH shall not disclose information to a person or body or agency except as listed in Rule + Level: 1 + Aligned at: 0.63 cm + Indent at: 1.27 cm 10 above. • Rule Principle 12 – Unique Identifiers Formatted: Indent: Left: 0 cm, Hanging: 0.5 cm, Bulleted NBPH shall not assign a unique identifier unless it is necessary to carry out any one of + Level: 1 + Aligned at: 0.63 cm + Indent at: 1.27 cm more of its functions efficiently e.g. patient surveys. If unique identifiers are assigned NBPH will take all reasonable steps to ensure that the identifiers are only assigned to individuals whose identity is clearly established. NBPH does store information by National Health Index (NHI) number. If information is identifiable, it will be stored in accordance with Rule 5.
NOTE: If information is stored in a totally anonymous manner and the individual is not identified, some components of this policy do not apply. If unsure, employees should check with their line manager or the Privacy Officer.
6. Related Documents
a) Privacy Principles (Appendix 1) b) NBPH Confidentiality Policy c) NBPH Building Security Policy d) NBPH Code of Conduct
Nelson Bays Primary Health Organisation Policy: Privacy Policy Authorised by: Issue Date: August 2013 Review Date: May 2020 Version: 3 Page 4 of 5 NBPH Board Version Date: May 2017
37 7. References
• Privacy Act 1993 • Privacy Principles https://privacy.org.nz/news-and-publications/guidance- resources/information-privacy-principles/ • Health Information Privacy Code 1994 https://www.privacy.org.nz/the-privacy-act-and- codes/codes-of-practice/health-information-privacy-code/ • On the Record: A Practical Guide to Health Information Privacy, 2nd edition, July 2000 https://privacy.org.nz/assets/Files/2206963.pdf • The Health (Retention of Health Information) Regulations 1996 • Medicines Regulation 1984, clause 58.
Approved By: NBPH Board
Nelson Bays Primary Health Organisation Policy: Privacy Policy Authorised by: Issue Date: August 2013 Review Date: May 2020 Version: 3 Page 5 of 5 NBPH Board Version Date: May 2017
38 39 40 APPENDIX 3
TITLE: Deputy Chairperson Selection Policy
1. Statement / Purpose
In accordance with the Trust Deed one of the Trustees will be Deputy Chairperson.
2. Scope
The policy applies to the Deputy Chairperson of the Trust Board of Nelson Bays Primary Health (NBPH).
3. Definitions
To support the Chairperson and deputise in their absence. This important role is a standalone position and is not a succession step. Appointment of this position is to be done in isolation of any appointment or planning of the Chairperson position.
4. Selection Process
The Deputy Chairperson shall be appointed annually by majority vote of the Board at the first Board meeting following the Annual General Meeting (AGM). If circumstances arise whereby a Deputy Chairperson needs to be appointed between AGMs then that appointment shall end at the first Board meeting following the next AGM.
The retiring Deputy Chairperson is eligible for re-appointment.
• The Chairman shall notify all Trustees at the September meeting that expressions of interest for Sub-committee appointments are to be received at least 7 days prior to the first Board meeting following the AGM • All members of the Board who are interested in applying for this position should email the Chair at least 7 days prior to the first Board meeting following the AGM expressing their interest in the position • If there is only one Trustee interested, then that Trustee shall be automatically selected, provided however, that the Chair retains the right to reject the candidate for good reason • If more than one candidate is interested, then candidates will be asked to leave the room during the period in which the Board discusses the candidates and determines the appointments by vote, provided however, that the Chair retains the right to reject the candidate for good reason
5. Related Documents a) Deputy Chairperson Position Description
6. References
N/A
Nelson Bays Primary Health Organisation Policy: Deputy Chairperson Selection Policy Authorised by: Issue Date: March 2014 Review Date: May 2020 Version: 5 Page 1 of 2 NBPH Board Version Date: May 2017 41 Approved By: NBPH Board
Nelson Bays Primary Health Organisation Policy: Deputy Chairperson Selection Policy Authorised by: Issue Date: March 2014 Review Date: May 2020 Version: 5 Page 2 of 2 NBPH Board Version Date: May 2017 42 APPENDIX 4
TITLE: Independent Chairperson Selection Policy
1. Statement / Purpose
In accordance with the Trust Deed, one of the Trustees will be a Chairperson selected independently of the three representative groups – community, iwi/Māori community and contracted provider.
2. Scope
The policy applies to the Chairperson of the Trust Board of Nelson Bays Primary Health (NBPH).
3. Definitions
“Independent Chairperson” refers to the background of the Chairperson and the method by which they were selected, it does not, however, mean that the Chairperson is there to represent their own interests. Once confirmed as Chairperson they have a legal duty to do all things and make all decisions in the best interests of NBPH.
4. Background
The Independent Chairperson is selected for a three year term.
Prior to the July meeting in their third year of appointment, the Chairperson will discuss their availability for a further term. At the July meeting the Board (without the Chairperson) will discuss the on-going availability and suitability of the current Chairperson and decide whether to offer a further three-year term to the incumbent or whether to advertise for a new Independent Chairperson. It is acknowledged that the latter selection may simply be to seek a change in direction or skills and should not be seen to reflect negatively on the incumbent.
If the Chairperson resigns, dies or otherwise leaves the Trust Board earlier than their three year term then the Deputy Chairperson will deputise in their absence until such time as a new Independent Chairperson has been selected.
5. Selection Process
A Selection Panel consisting of the Deputy Chairperson, and the Chairs of Governance and Remuneration and Audit and Financial Risk Subcommittees (with the option of additional clinical representation if providers are not adequately represented) will oversee the appointment of the Chair.
Prior to advertising, the Selection Panel needs to review the existing position description and person specification and previous advertisement, with any changes to be signed off by the Board.
Nelson Bays Primary Health Organisation Policy: Independent Chairperson Selection Policy Authorised by: Issue Date: March 2013 Review Date: May 2020 Version: 5 Page 1 of 2 NBPH Board Version Date: May 2017 43 The Selection Panel will establish a timeline to be presented to the Board.
• Draft timeline with dates and emailed out to all Trustees for comment • A reviewed position description and person specification, previous advertisement and a weighted criteria for shortlisting to be prepared by the Selection Panel and emailed out to all Trustees for comment • All comments to be sent to and collated by Selection Panel • The reviewed documentation to be approved at the next Board meeting
Advertise in relevant print media, NBPH and DHB websites, NZ Institute of Directors and other avenues as appropriate.
The Selection Panel will review the interview questions, shortlist and interview candidates, and references of recommended candidates to be contacted. A search utilising media search will be undertaken.
The Board will meet with the recommended candidates prior to discussing appointment to determine the “fit” with the Board, the NBPH in general, our enrolled population, providers, community and iwi. There will also be a limited opportunity to pose any questions, however, this is considered a “meet and greet” rather than a second interview.
The Board will make the final selection. The appointee to be confirmed at the AGM (or by Special Resolution in the event of the Chairperson not seeing out their full term).
Advertise in the Nelson Mail, Community Newspapers, NBPH and DHB websites, NZ Institute of Directors and other avenues as appropriate.
Selection Panel to review interview questions, shortlist and interview candidates, and references of recommended candidates to be contacted. A media search to be undertaken.
Board to meet with the recommended candidates prior to discussing appointment to determine “fit” with the Board, the NBPH in general, our enrolled population, providers, community and iwi. There will also be a limited opportunity to pose any questions, however, this is considered a “meet and greet” rather than a second interview.
Board will make final selection. Appointee to be confirmed at the AGM (or by Special Resolution in the event of the Chairperson not seeing out their full term).
6. Related Documents
a) Independent Chairperson Position Description
7. References
N/A
Approved By: NBPH Board
Nelson Bays Primary Health Organisation Policy: Independent Chairperson Selection Policy Authorised by: Issue Date: March 2013 Review Date: May 2020 Version: 5 Page 2 of 2 NBPH Board Version Date: May 2017 44 APPENDIX 5
TITLE: Subcommittee Selection Policy
1. Statement / Purpose
The term of appointment for Board subcommittees is to be reviewed annually at the Board Meeting following the Annual General Meeting (AGM).
2. Scope
The policy applies to the Audit and Financial Risk subcommittee and the Governance and Remuneration subcommittee.
3. Expectations
The expectation in respect of the membership of the subcommittees is: • An interest in the responsibilities delegated to that subcommittee (existing expertise is not necessary) • The term of the appointment is for a period of one year, but in the interests of continuity candidates should anticipate 3 years’ service • Candidates due to (or intending to) retire from the Trust Board prior to the end of the 1 year term are not eligible to apply • There is the abilityshould be the ability to have alternates/proxy at the meetings • All Board members have the right to attend subcommittee meetings but not the right to vote
4. Selection Process
The number of candidates appointed to the subcommittee is governed by the relevant subcommittee’s Terms of Reference.
The process for appointment is: • The Chairman shall notify all Trustees at the AGM that expressions of interest for subcommittee appointments are to be received at least 7 days prior to the Board meeting following the AGM • All members of the Board who are interested in a position on a subcommittee should email the Chairman expressing their interest • If there are an equal or lesser number of Trustees interested than positions available, then all Trustees shall be automatically selected • If there are more candidates than positions available on a subcommittee, then candidates will be asked to leave the room during the period in which the Board discusses the candidates and determines the appointments by vote • Non-Trustee members may be seconded onto the subcommittees in accordance with the Terms of Reference of the subcommittees • At the first meeting of the subcommittee the members shall select a Chairman of the subcommittee from within their own members
Nelson Bays Primary Health Organisation Policy: Subcommittee Selection Policy Authorised by: Issue Date: March 2013 Review Date: May 2020 Version: 4 Page 1 of 2 NBPH Board Version Date: May 2017 45 5. Related Documents
N/A
6. References
N/A
Approved By: NBPH Board
Nelson Bays Primary Health Organisation Policy: Subcommittee Selection Policy Authorised by: Issue Date: March 2013 Review Date: May 2020 Version: 4 Page 2 of 2 NBPH Board Version Date: May 2017 46 APPENDIX 6
TITLE: Fixed Asset Management Policy
1. Statement / Purpose
To ensure that capital expenditure by the Trust is planned, authorised, monitored, recorded and reported to meet the objectives of best practice.
2. Scope
The policy applies to all fixed asset and lease transactions within NBPH.
3. Definitions
Assets are future economic benefits controlled by NBPH as a result of past transactions or events.
Work in progress, intangible assets, current assets and investments also meet the asset definition but are not covered by this policy.
A capitalised asset (or fixed assets) results from also meeting all of the following conditions: • Item has an estimated useful life of > 1 year; • Has a cost that satisfies the capitalisation threshold which is set at $500; • Has not been acquired or constructed with the intention of resale; and • May include expenditure incurred to improve its functionality and/or extend its useful life.
This policy is to cover fixed assets and assets recognised as a result of entering into a finance lease. Also, the process for entering into an operating leases is to follow the fixed asset management policy where applicable. For operating leases, the net present value is the deemed purchase price.
4. Planning for Capital Expenditure
This process involves: • Annual and long-term planning of capital expenditure, including prioritisation and ranking of capital expenditure; • Preparation and submission of requests to proceed with capital expenditure; and • The review and scheduling of capital expenditure.
4.1 In line with the delegations policy, the Board approves the capital expenditure budget established by management for a one year period. Capital expenditure is approved by the board for specific categories.
Capital allocations for major projects also form part of the total capital expenditure allocated for a given year.
Nelson Bays Primary Health Organisation Policy: Fixed Asset Management Policy Authorised by: Issue Date: March 2009 Review Date: May 2020 Version: 5 Page 1 of 9 NBPH Board Version Date: May 2017 47 4.2 Capital Expenditure planning details: • Current stock of assets held, outlining the replacement programme required to maintain this stock, • Shortages in the current assets and the plan and timing to address these, • Assets required for new approved programmes or growth in existing programmes, and • Assets associated with new building projects.
Capital expenditure is to be prioritised where not all demands can be met.
The Capex Schedule which details the asset purchases proposed for the coming year can then form an internal capital expenditure control mechanism for management.
4.3 Requests to proceed with capital expenditure for IT-related equipment are to be forwarded to Information Systems Coordinator (Appendix A & B). The relevant forms are attached to this policy.
Requests to proceed with capital expenditure (other than IT-related equipment) are to be forwarded to the accountant using the form attached (Appendix C).
The approval process is outlined under 5. Approval and acquisition of Fixed Assets below.
4.4 Capital expenditure is reviewed on an on-going basis by the accountant and reporting is made available to the board.
5. Approval and Acquisition of Fixed Assets
5.1 Approved capital expenditure budgets do not constitute authorisation to incur the expenditure. Applicants are required to complete and submit a Capital Expenditure Form to obtain approval to proceed with the expenditure in accordance with delegated authorities.
5.2 Delegated authorities for approval to proceed with budgeted and unbudgeted capital expenditure are detailed as per the Delegations Policy. These delegations apply to all capital expenditure.
5.3 A single Capital Expenditure Form may be prepared for a project. The accountant is to put in place control mechanisms to track individual purchases that form a project or collective purchase. Use of project codes is recommended as a control mechanism.
5.4 Proposals for the acquisition of leased assets must adhere to the same policy as the outright purchase of assets if they are to be recognised as fixed assets (finance lease).Leasing an asset by entering into a finance lease involves substantially the
Nelson Bays Primary Health Organisation Policy: Fixed Asset Management Policy Authorised by: Issue Date: March 2009 Review Date: May 2020 Version: 5 Page 2 of 9 NBPH Board Version Date: May 2017 48 same benefits, costs and risks as purchase and so the same decision making framework is required.
5.5 Delegated authority levels for acquisition by lease are based on purchase price, not annual lease payment or total lease commitment. All financial details of the leased asset are to be supplied to the Accountant, and leased assets are to be recorded in the Asset Register.
5.6 The estimated timing of capital expenditure approved is an important element in projecting the cashflow position and must be indicated on the fixed asset request form.
6. Fixed Asset Recording Process
6.1 The invoice is to be accompanied by a copy of the approved fixed asset request form. Authorisation of the invoice is to follow delegations policy.
6.2 The barcode sticker is to be adhered to the fixed asset item as soon as it is received. The details of the barcode are to be recorded on the tax invoice. A photocopy of both invoice and fixed asset request form is to be taken.
6.3 All relevant details of the fixed asset items purchased are to be recorded in the Fixed Asset Register with the supporting documentation filed.
6.4 Where an asset is constructed or acquired and the cumulative costs are being recorded as work in progress, these costs must be transferred to the asset register on completion.
7. Fixed Asset Disposal Process
7.1 On disposal or sale of any fixed asset items, a Sale/Disposal form is to be completed and forwarded to the accountant (Appendix D). Any sales or disposals are to be authorised as per delegations policy.
7.2 Adjustments will be made in the Fixed Asset Register and the necessary General Ledger entries processed.
7.3 Fixed Assets which cannot be located during the annual stock take, or are damaged beyond repair, are to be disposed of. The disposal form is still required and is to be approved in line with the delegations policy.
7.4 Where an asset has been lost, stolen or maliciously damaged, the accountant is to be informed and the matter will be referred as appropriate to police and/or insurance brokers. Assets that are lost, stolen or damaged beyond repair are to be disposed of. Any proceeds received from the insurance companies are to be recognised as income.
Nelson Bays Primary Health Organisation Policy: Fixed Asset Management Policy Authorised by: Issue Date: March 2009 Review Date: May 2020 Version: 5 Page 3 of 9 NBPH Board Version Date: May 2017 49 8. Fixed Asset Stock Take
8.1 An internal fixed asset stock take is to be conducted annually by the accountant, with the objective being to maintain the integrity of the Fixed Asset Register. This is achieved by: - ensuring that all assets held are recorded in the Fixed Asset Register; - verifying that all assets in the Fixed Assets Register have been physically located and are still functional; - updating the Fixed Asset Register for changes in location. - updating the Fixed Asset Register for any impairments
8.2 The stock take is to be formally recorded and records are to be signed.
8.3 Where it is ascertained that assets in the Fixed Assets Register either no longer physically exist, or are damaged and non-functional, refer to point 7 of this policy.
9. Related Documents
a) Appendix 1: NBPH New Staff Member IT Requirements Form b) Appendix 2: NBPH Replacement IT Requirement Form c) Appendix 3: NBPH New or Replacement Fixed Assets Form d) Appendix 4: NBPH Asset Disposal Form
10. References
N/A.
Approved By: NBPH Board
Nelson Bays Primary Health Organisation Policy: Fixed Asset Management Policy Authorised by: Issue Date: March 2009 Review Date: May 2020 Version: 5 Page 4 of 9 NBPH Board Version Date: May 2017 50 APPENDIX 1: Nelson Bays Primary Health New Staff Member IT Requirements Form
Please ensure that this form is completed and returned to IT within 10 working days of the start date of the new staff member, or IT cannot guarantee that all equipment will be set-up by their start date. New Staff Name FTE Job Title Start Date Line Manager
Computer Health & Safety Issues (Note any potential Health & Safety Issues or Requirements) Requirements (please tick) Office Based Staff Desktop PC Single Monitor, or Dual Monitors
Or, Mobile Staff i.e. Staff who are required to work on their computer out of the office
Laptop, or Notebook Docking Station Single Monitor, or Dual Monitors
Communication Desk Phone Direct Dial Devices Cellphone (please tick) Other
Software & Email Web Browser Services Office MedTech MYOB Other (please specify)
R:\ Drive access (please specify)
Checked By IT: …………………………...... Authorised By: ………………………………….. Accountant Updated: ………………………………….. Within IT Budget: …………………………………..
Nelson Bays Primary Health Organisation Policy: Fixed Asset Management Policy Authorised by: Issue Date: March 2009 Review Date: May 2020 Version: 5 Page 5 of 9 NBPH Board Version Date: May 2017 51 Computer Requirements Please consider this carefully. It is time consuming to set up a user with a new computer if the wrong one is chosen.
Laptops are more expensive, more work to maintain, and less powerful than comparable desktop models and so should only be considered where the user is expected to work on their computer out of the office.
Notepads are similar to laptops but are generally smaller. They should be considered when the user needs to be highly mobile, and needs to perform only basic work (e.g. email, web browsing) on a computer out of the office.
Single Monitor or Dual Monitors Dual monitors are at least twice as expensive as single monitors, and so should only be considered where the user is required to do lot of work on their computer that would require the user to be working with several programmes at the same time. Users who mainly use email, web and Office probably don’t need dual monitors.
Docking Stations Docking stations should be considered for laptop/notebook users who have laptops with smaller screens, but need to do a large amount of work in the office. Laptop users with larger screens may find that they can just use a mouse and/or keyboard with their laptop when at their desk, as it will clutter up their desk less.
Communication Devices Direct dial numbers are limited, and so should only be considered for users who will take frequent calls.
Cellphones should only be considered for users who will take and make frequent calls out of the office. Pre-paid phones may initially be offered to users, to gauge the level of use before committing to a fixed term contract. iPhones and iPads should only be considered for senior staff who are expected to be highly available and need to be able to read and answer emails anywhere.
Software & Services These should be fully detailed, as they will be used to select the appropriate computer equipment.
Nelson Bays Primary Health Organisation Policy: Fixed Asset Management Policy Authorised by: Issue Date: March 2009 Review Date: May 2020 Version: 5 Page 6 of 9 NBPH Board Version Date: May 2017 52 APPENDIX 2: Nelson Bays Primary Health Replacement IT Requirement Form
Staff Member Requiring New Equipment
Equipment Required Equipment description:
New Equipment Or, Replacement Equipment
Reason Equipment is Required (please specify)
Health & Safety Issues
Checked By IT: Authorised By: Accountant Updated: Within IT Budget:
Nelson Bays Primary Health Organisation Policy: Fixed Asset Management Policy Authorised by: Issue Date: March 2009 Review Date: May 2020 Version: 5 Page 7 of 9 NBPH Board Version Date: May 2017 53 APPENDIX 3: Nelson Bays Primary Health New or Replacement Fixed Assets Form
Staff Member Requiring New Equipment
Equipment Required Equipment description:
New Equipment Or, Replacement Equipment
Reason Equipment is Required (please specify)
Health & Safety Issues
Authorised By: Accountant Updated: Within Capex Budget:
Nelson Bays Primary Health Organisation Policy: Fixed Asset Management Policy Authorised by: Issue Date: March 2009 Review Date: May 2020 Version: 5 Page 8 of 9 NBPH Board Version Date: May 2017 54 APPENDIX 4: Nelson Bays Primary Health Asset Disposal Form
ASSET NUMBER*
DESCRIPTION**
SOLD DISPOSED OF DONATED
SOLD FOR: $
DISPOSED OF:
DONATED TO:
AUTHORISED BY:
Accountant updated:
Nelson Bays Primary Health Organisation Policy: Fixed Asset Management Policy Authorised by: Issue Date: March 2009 Review Date: May 2020 Version: 5 Page 9 of 9 NBPH Board Version Date: May 2017 55 To Nelson Bays Primary Health Board From Emily-Rose Richards, Executive Assistant/Board Secretary Endorsed by Angela Francis, Chief Executive Meeting Date 1 June 2017 Subject Position Descriptions for Approval
For approval √ For action √ For information
1. PURPOSE
To provide the Board with updated Position Descriptions, which require the Board’s approval.
2. SUMMARY OF POSITION DESCRIPTIONS
At the Audit and Financial Risk Committee meeting on 12 April 2017, the following Position Description amendments were agreed on:
Independent Board Chairperson Position Description The Independent Board Chairperson Position Description was recommended to the Board for approval, subject to the following amendments being made: • Amendments to page 1, key tasks, bullet point 12 to read: ‘Along with the Governance and Remuneration Committee Chair, monitor and appraise the performance of the CE (including an annual performance appraisal).’
Refer to Appendix 1 for the Independent Board Chairperson Position Description.
At the Governance and Remuneration Committee meeting on 10 April 2017, the following Position Description amendments were agreed on:
Trustee Position Description and Person Specification The Trustee Position Description and Person Specification was recommended to the Board for approval, subject to the following amendments being made: • Amend ‘three Trustees’ to read ‘two Trustees’ throughout document
Refer to Appendix 2 for the Trustee Position Description and Person Specification.
3. RECOMMENDATION
It is recommended that the Board approves the: • Independent Board Chairperson Position Description and Trustee Position Description and Person Specification.
Appendices: 1 Independent Board Chairperson Position Description 2. Trustee Position Description and Person Specification
56 APPENDIX 1
Independent Board Chairperson Position Description Nelson Bays Primary Health (NBPH)
To be responsible for the overall governance of NBPH and uphold the vision, culture and values of the organisation.
Key Tasks:
• Provide leadership and direction to the NBPH Board, consistent with the strategic and operational plans of the organisation. • Chair the monthly meetings of the Trustees, the Annual General meeting and any other extraordinary meetings of the Board in an independent and fair manner, allowing the views of all Board members to be heard and considered. • Submit a report for the monthly Board Meeting Agenda. • Guide the planning processes of the Board, including its strategic, annual and operational plan formulation, and any other relevant planning functions. • Ensure that the Board annually reviews the NBPH Strategic Plan and operational budget and that it is advised of any substantial variances (and proposed remedial actions if required), against the budget. • Ensure the Board is responsible and accountable in its processes and decision- making, implementing accepted best practice governance and codes of conduct. • Ensure the Board complies with its reporting responsibilities as per its contracts with the Nelson Marlborough District Health Board and any other funder. • Ensure the NBPH complies with all relevant legislation and legal documents such as NBPH Trust Deed, Charities Act and New Zealand Public Health and Disability Act 2000. • Ensure the financial statements are independently audited annually and that the NBPH complies with any related matters. • Ensure the Board regularly and thoroughly monitors risks in line with the applicable policies. • Maintain a strong relationship with the CE to ensure the CE understands and appropriately performs in his/her role. • Along Wwith the Governance and Remuneration SubcCommittee Chair, monitor and appraise the performance of the CE (including an annual performance appraisal). • To be the public face of NBPH and competently respond to the media as per the NBPH policy guidelines. • Monitor and manage Board performance including individual performance and oversee periodic Board performance review. • Maintain a close professional relationship with the Deputy Chair. • Adhere to all organisational policies.
Desired Skills and Expectations:
The chairperson of the Board should demonstrate all or most of the following attributes: • Experience and excellence in best practice governance. • Sound leadership skills with a strategic focus. • The ability to manage and guide the CE and build a close and effective working relationship with him/her.
Nelson Bays Primary Health Organisation Position Description: Independent Board Chairperson Authorised by: Issue Date: 2007 Review Date: May 2018 Version: 4 Page 1 of 2 NBPH Board Version Date: May 2017 57 • Knowledge of or a willingness to learn about the public health sector particularly primary health and general practices in private business. This includes populations with high health needs and/or poor health outcomes including tangata whenua. • An ability to maintain professional detachment and independence. • Chairmanship skills that strive to achieve consensus where members’ opinions are diverse. • Excellent communication and relationship skills. • Ensure the role of the Chair enjoys the confidence of the Board. • Knowledge of or a willingness to learn about the key stakeholder areas NBPH engages with. • A good understanding of employment matters and expectations of employers. • An excellent understanding of financial management systems including understanding financial statements and balance sheets. • Experience in organisational, strategic and annual planning and budgeting. • An understanding of the legal and contractual requirements of public organisations, including charitable trusts. • Must be computer literate.
Time Commitment
Meetings: Regular monthly Board meetings, Annual General Meeting and any extraordinary meetings and representing the Board at meetings on its behalf.
Other: Agenda preparation, checking minutes and ensuring actions are followed up. The oversight and preparation of specific papers for the Board to consider. Manage the relationship with the CE – minimum of 4 hours a month. Time for reading the agenda and other relevant papers (e.g. NMDHB agenda and minutes plus other relevant publications and policy. Travel to national and regional meetings.
A minimum time commitment of 20 hours per month.
Term of Office Three years from time of appointment.
Remuneration Honorarium paid, commensurate with qualification sand experience (reviewed annually).
Nelson Bays Primary Health Organisation Position Description: Independent Board Chairperson Authorised by: Issue Date: 2007 Review Date: May 2018 Version: 4 Page 2 of 2 NBPH Board Version Date: May 2017 58 APPENDIX 2
TITLE: Trustee Position Description and Person Specification
1. Statement/Purpose
To ensure that three two Trustees nominated by contracted providers provide the perspective of the health sector onto the Nelson Bays Primary Health Trust Board; three two Trustees nominated by the community, government departments, local authorities or community organisations provide the perspective of the wider Nelson/Tasman community onto the Nelson Bays Primary Health Trust Board; and three two Trustees nominated by local Iwi/Maori provide the perspective of the Iwi/Maori community onto the Nelson Bays Primary Health Trust Board.
2. Scope
The policy applies to all NBPH Trustees.
There are separate position descriptions and selection policies for the Independent Chair and Deputy Chair, however there is the expectation that they will fulfil, as a minimum, all of the key tasks and hold the desirable skills as contained in this policy.
3. Definitions
Once confirmed as a Trustee, all Trustees have a legal duty to do all things and make all decisions in the best interests of Nelson Bays Primary Health.
4. Key Tasks
To be a fully participating member of the NBPH Board, committed to the vision and culture of the organisation and to abide by the decision and policy directions agreed by the Board.
• To take part in monthly meetings of the Board, and any other extraordinary meetings called by the Chairperson; participating and contributing to the overall governance responsibilities of the Board and acting in accordance with the policies and procedures adopted by the Board, • To study and review Board agendas, papers and background materials relating to Board affairs prior to Board meetings, • To present the views of the constituency represented by the member at Board meetings, • To acknowledge and respect the views of other Board members, • To present the values and policies of the Board to relevant interest groups and to the public at large, • To canvass the views and opinions of the constituency groups represented, so that the Board can function with knowledge of stakeholder interests, in order to serve the entire Nelson Bays population. • To undertake special tasks and responsibilities as approved by the Board.
Nelson Bays Primary Health Organisation Position Description: Trustee Position Description and Person Specification Authorised by: Issue Date: May 2014 Review Date: May 2018 Version: 3 Page 1 of 2 NBPH Board Version Date: May 2017
59 5. Desirable Skills
Board members should demonstrate some or all of the following attributes:
• A good knowledge of the health sector, particularly the primary health field and an understanding of the views and aspirations of the community represented, • An ability to contribute to meetings in a fair, balanced and considered fashion, • An ability to present and convey information in a straightforward fashion, • An ability to evaluate reports, assess data and to enquire when further information is needed, • Governance experience • Excellent communication and relationship skills, • Knowledge of financial statements and balance sheets, • Demonstrated awareness of the cultural values of the community served, including local Tangata Whenua. • An understanding of the planning process – strategic plans and annual plans.
6. Time Commitment
• Monthly Board meetings and any extraordinary meetings - 4 hours minimum. • Preparation for meetings – additional. • Representing the Board at meetings called by other bodies. • Annual strategic planning day and training as required. • Additional duties as may be allocated to members, as agreed by the Board. • Members are expected to keep up-to-date on material issued about the primary health strategy, or relating to responsibilities of PHOs. • Members are expected to make themselves available for subcommittees and advisory groups.
7. Nomination
Nomination for Trustee vacancies will be in accordance with the specific Selection Policy for Trustee group.
8. Related Policies
• Community Representative Selection Policy • Iwi/Maori Community Representative Selection Policy • Contracted Provider Selection Policy • Deputy Chairperson Selection Policy • Deputy Chairperson Position Description • Independent Chairperson Selection Policy • Independent Chairperson Position Description
Nelson Bays Primary Health Organisation Position Description: Trustee Position Description and Person Specification Authorised by: Issue Date: May 2014 Review Date: May 2018 Version: 3 Page 2 of 2 NBPH Board Version Date: May 2017
60 Board Work Programme v 23 May 2017
2016 2017 Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec BOARD Meetings Richmond 7 4 TC 1 6 3 2 2 6 TC 4 1 6 3 7 5 2 Golden Bay 7 7 Strategic Planning Day 8 NBPH and MPH Board Meeting – Havelock NBPH and NMDHB Boards Meet and Greet 2 Events Board dinner 6 x Agenda items Board appointment process (A6) x Delegations policy (A9) x Appointment of Deputy Chair x x Subcommittee appointments review x x Review of Trustee Register/Reappointment x Process Approve audited financial statements x x Approve 2017/18 Budget x Other Review annual formal appointments of Board x x members to AFRIC and Gov and Rem Send Fit and Proper declarations to Trustees x for completion Management to provide Solicitor’s review of x NBPH’s statutory compliance register Management to provide summary paper x from Solicitor on new legislation relevant to the Board, as required COMMITTEES Remuneration and Governance Meetings 4 28 7 10 15 9 Chief Executive Staff/Providers/Stakeholders Survey – carry x performance out appraisal Staff/Providers/Stakeholders Survey – review x Chief Executive performance appraisal 22 Agenda items Review of Trustee Register/Reappointment x Process Board Appraisal (every 2 years) x Review of Terms of Reference (every 2 years) x Trustee Position Description x Other Review Fit and Proper declarations x
61 2016 2017 Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Audit and Financial Risk Meetings 1 12 7 Agenda items Review and recommend the budget x Consider year-end audited financial x x statements Meeting with Auditor/Setting Audit Fee x Reappointment of Auditor x x Insurance of renewal review x Review of Reporting to Board x Review of Terms of Reference (every 2 x years), Chair, Committee Performance Te Tumu Whakaora Meetings 21 15 20 17 16 16 18 15 20 21 19 16 Clinical Governance Committee Meetings 21 15 20 17 16 16 18 15 20 21 19 16 AGM Meeting x x Agenda items Adopt Annual Report x x Appoint Auditors for next financial year x x OTHER Strategy and Budget Cycle Strategic Planning Day 8 Strategic Plan Annual Plan Audit x x Budget process x x x Consider 2017/18 Budget x Marlborough Primary Health Board meetings Blenheim 10 2 14 25 8 19 12 23 8 13 AGM Blenheim 21 27 Public Holidays Nelson Anniversary Day 30 Waitangi Day 6 Good Friday 14 Easter Monday 17 Anzac Day 25 Queen’s Birthday 5 Labour Day 24 23
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