Improving Effectiveness in Health Care Service Delivery David Dean, PhD General Manager, The Health

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Improving Effectiveness in Health Care Service
DeliveryDavid Dean, PhDGeneral Manager,
The Health RoundtableInstitute of Public
Administration AustraliaHobart, 4 November 2005
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Key messages

• Australia has excellent health outcomes
• However, the health system is under intense and
  growing pressure
• Hospitals are at the epicentre of this pressure
• Maintaining our excellent outcomes will require
• Accountable organisations
• Effective leaders
• Peer-to-peer benchmarking assists hospital
  leaders find innovative solutions

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Some Background

• David Dean
• PhD in Social Science in 1978
• Ten years as management consultant with
  Booz-Allen Hamilton
• Led hospital improvement projects in Australia in
  early 1990s
• Set up own consulting business in 1993
• Australian citizenship in 1995
• General Manager of The Health Roundtable since
  1995

• The Health Roundtable
• Founded in 1995 by Bill Kricker and John Youngman
• Non-profit membership organisation open to major
  public hospital chief executives
• Shares operational problems and innovations at
  hospital level
• Started with 7 members in 1995
• Has grown to 34 members in 2005 about 1/3rd of
  all public hospital inpatients

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The Health Roundtable An Innovation
Clearinghouse
Background

• Health care from hospital perspective
• Operational focus
• Share problems
• Share innovations
• No role in public policy setting
• No direct government funding
• Provide CEO information network

Health Roundtable
UHC
IHI
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34 Organisational Members over 50 Hospital
facilities
Background
Plus Regional Health Improvement Network
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Australias health care system has delivered
excellent outcomes
Outcomes
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Low declining infant mortality
Outcomes
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High improving life expectancy
Outcomes
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Lower standardised mortality rate
Outcomes
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Health Costs 20 Higher than UK - Half of USA
Outcomes
Source Australias Health 2000, 2004
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A Good Health Care Report!
Outcomes
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But can we maintain these outcomes?
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Ageing of the population
Pressures
Source Productivity Commission, 1999
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Global consumer access to information - aortic
aneurysm example
Pressures
26,600 pages
2001
2005
1,040,000 pages
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New (expensive) treatments
Pressures
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Dramatic rise in drug expenses
Pressures
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Health Costs growing 6.9 pa - much faster than
the economy as a whole
Pressures
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Health care now costs 4,000 per person
Pressures
Source, Australias Health 2000,2004
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Ageing Workforce
Pressures
US example
Source http//bhpr.hrsa.gov/healthworkforce/repo
rts/rnproject/report.htm
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Global competition for health workers
Pressures
USA alone short 500,000 nurses
http//bhpr.hrsa.gov/healthworkforce/reports/rnpro
ject/report.htmchart1
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Key messages

• Australia has excellent health outcomes
• However, the health system is under intense and
  growing pressure
• Hospitals are at the epicentre of this pressure
• Maintaining our excellent outcomes will require
• Accountable organisations
• Effective leaders
• Peer-to-peer benchmarking assists hospital
  leaders find innovative solutions

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These pressures are focused most acutely on
hospitals
Hospital Epicentre
Hospitals
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Pressures on the Health System
Hospital Epicentre
Hospitals
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Expecting 25 growth in elderly (80) this decade
to 3.9 of population
Hospital Epicentre
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Over 80s already 11 of all Patients
Hospital Epicentre
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. . . and 22 of all emergency beddays
Hospital Epicentre
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Elderly use 8 times as many bed days as younger
people
Hospital Epicentre
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Pressures on the Health System
Hospital Epicentre
Hospitals
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Hospital Epicentre

• Robotic
• Surgery

http//www.cts.usc.edu/rsi-davincisystem.html
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New Knowledge and Technologies
Hospital Epicentre

• Genomics
• Proteomics
• Metabolomics
• Molecular Imaging
• Nanotechnology
• Bioinformatics
• Molecular Therapeutics
• Molecular Imaging

National Cancer Institute
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Pressures on the Health System
Hospital Epicentre
Hospitals
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Public Hospital funding share continues to
decline now below 35
Hospital Epicentre
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Little new overnight bed capacity added to the
system in a decade
Hospital Epicentre
Source AIHW Hospital Statistics, Table 2.3
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Most growth has been in same-day admissions
Hospital Epicentre
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while public hospital bed nights have dropped
almost 1 per year
Hospital Epicentre
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Increases in Emergency medical patients have led
to reductions in Elective surgical patients
Hospital Epicentre
Emergency up 600 beds
Elective down 760 beds
Source HRT, Bed Occupancy.xls
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with Emergency patients occupying over 62 of
beds, up from 56 in 1996
Hospital Epicentre
Source HRT, Bed Occupancy.xls
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VOLUME PREDICTIONSPredicting the Future is
Tricky!
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Predictions from 1991 predicted 28 fewer bed
days than actually used in 2001
Predictions
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An additional 1.8 million bed nights (5,000 beds)
will be needed by 2011
Predictions

• Due to elderly growth population growth at
  current levels of hospital usage
• ... Creating more strain on public and private
  hospital systems

Source AIHW, ABS, Chappell Dean analysis
same-day stays excluded from calculations
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Alternative is to make dramatic reductions in
elderly length of stay
Predictions

• 17 reduction in acute length of stay for elderly
• Overall 6 reduction needed to keep occupancy at
  current levels

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Pressures on the Health System
Hospital Epicentre
Hospitals
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Medical Workforce Example
Hospital Epicentre

• All hospitals are experiencing some staffing
  shortages related to larger, system-wide
  problems such as
• Number of places available in Australian
  medical courses and training programs
• Increasing reliance on overseas trained
  doctors, and
• Changes in the work aspirations and
  expectations of new generations of doctors.

THE PUBLIC HOSPITAL MEDICAL WORKFORCE IN
AUSTRALIA, AMWAC Report 2004.3 August 2004
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Nursing Workforce Example
Hospital Epicentre

• August 2004 Nursing Workforce Advisory
  Committee
• Shortfall of 5,504 nurses in 2006
• Shortfall of 8,329 nurses in 2012
• AHWAC 2004.2

Unprecedented shortages are forecast, but
the solutions are train more of the same rather
than redesign the work
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We have met the enemy, and he is us
Hospital Epicentre
Pogo, Earth Day 1971
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Our own worst enemy ...
Hospital Epicentre

• Rigid work demarcations
• Professional entry barriers
• Silos of expertise
• Endless paper documentation
• No memory beyond patient discharge
• Five-day culture for a seven-day problem
• Lack of leadership and direction
• Rearrange the deck chairs solutions

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Every system is perfectly designed to produce the
results it gets.(D. Berwick)
Key Principles
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How to Improve Effectiveness?

• Accountable Organisations
• Effective Leaders

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Accountable Organisations required in a rapid
change environment

• Clear Goals
• Clear Accountability for Results
• Agreed Resources
• Delegated Responsibility
• Long-term Vision

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Accountable Organisations
Accountability Hierarchy E. Jaques
Source W A Kricker, 2004
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Resource Centre Managers
Accountable organisations
Source W A Kricker, 2004
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Resource Centre Building Blocks
Accountable organisations
Chief Executive

• Clear accountability
• Clear task definition
• Clear output expectation
• Clear output measurement
• Rapid feedback
• Single source of funds
• Clear operational plan

Department / Clinical Stream
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Devolution of decision making
Accountable organisations

• Complexity and Rapid Change require devolution of
  decision making
• Central planning works only in stable, routine
  environment
• Optimal working unit size less than 150 people
• Highly skilled resource managers are incompatible
  with central planning
• Clear accountability for resources and results is
  essential
• Health organisations need devolution for
  competent patient care

Sources E Jaques, W Kricker, M Gladwell
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Resource Centre structure allows views from
multiple directions
Accountable organisations
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Long-term Vision Tenure Required to Manoeuvre
the Healthcare Supertanker
Accountable organisations

• Elliott Jaques research in 1970s and 80s
• Major Facility Managers need ability to plan
  5-10 years ahead
• Health System Leaders need ability to plan 10-20
  years ahead

Source E Jaques, Requisite Organisation, 1989
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Accountable Health Care Organisations in
Australia?

• Clear Goals
• Clear Accountability for Results
• Agreed Resources
• Delegated Responsibility

• Too many goals
• Rapid turnover of executives
• Capped budgets but uncapped expectations
• Increasing centralisation

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We have no shortage of national priorities
Clear Goals?

• Seven national health priority areas (NHPAs)
• arthritis and musculoskeletal conditions
  (osteoarthritis, rheumatoid arthritis,
  osteoporosis)
• asthma
• cardiovascular health
• cancer (breast, cervix, colorectal, non-Hodgkins,
  non-melanocytic skin, lung, lymphoma, melanoma
  and prostate)
• diabetes mellitus
• injury prevention and control
• mental health.

http//www.nhpac.gov.au/nhpas.htm
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but little translates to the actual health care
agreements with States
Clear Goals?

• 1. Eligible persons are to be given the choice
  to receive, free of charge as public patients,
  health and emergency services of a kind or kinds
  that are currently, or were historically,
  provided by hospitals.
• 2. Access to such services by public patients
  free of charge is to be on the basis of clinical
  need and within a clinically appropriate period.
• 3. Arrangements are to be in place to ensure
  equitable access to such services for all
  eligible persons, regardless of their geographic
  location.

http//www.health.qld.gov.au/publications/aust_hlt
h_care_agreement/Queensland.pdf
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provide free access within clinically
appropriate period
Resources and Responsibility?

• Who decides?
• What goal?
• How delivered?
• What resources?
• Penalty?
• Incentive?

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States differ in how accountability and
responsibility flow to hospitals
Resources and Responsibility?

• Victoria Regional health boards
• NSW Area health services
• Queensland Zones and Districts
• WA Regional health boards
• SA Metropolitan regions
• NZ District Health Boards

• Funding mechanisms
• Population resource allocations
• Casemix funding models
• Special grants
• Supplemental programs
• Activity targets
• Incentives Penalties
• Purchaser / Provider

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Victoria and New Zealand appear to have more
efficient systems
Resources and Responsibility?
Casemix Funding Accountable Boards
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Leadership is a key issue Average tenure at the
top only 2.5 years
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The Health Roundtable Role

• Explore key issues affecting hospitals
• Analyse benchmarking data with trusted peers
• Encourage short-cycle improvement projects
• Provide peer support

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Benchmarking for Innovations

• Voluntary comparisons
• Search for differences
• Data Methods
• Clinical Practices
• Accept approximate data
• No right or wrong
• Opportunity focus
• Gradual fine-tuning

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Not for Accountability to Government

• Mandated
• Uniform
• Tightly defined
• Score win/lose
• Denial by losers
• Gaming the system
• Inspectors needed

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We use data mining process to find interesting
differences

• Data aggregated at DRG level for each health
  service facility
• At least one facility must be 25 below the
  benchmark average to qualify for review
• Discuss the data with the lead hospital to
  identify innovative practices (or data glitch!)

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Case Study 1 Laparoscopic Cholecystectomy
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Good Practices Interview of Facility
--Same-Day Laparoscopic Cholecystectomy

• Screen for patients with normal anaesthetic
  ratings
• Schedule for morning list
• Extend day surgery recovery to 7pm
• Provide discharge meds kit for pain
• Follow up next day

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Case Study 2 Hip Revision or Replacement
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Good Practices Interview of FacilityHip
Revision or Replacement
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Knowledge of differences only the first step in
diffusion of innovative ideas
1.Knowledge
4. Implementation
Source Everett Rogers, Diffusion of
Innovations, 1995
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We use Roundtable discussions to share ideas and
promote action
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Other Innovations Spread by The Health Roundtable
The Roundtable Process
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Roundtable Success Factors

• Voluntary participation by hospital chief
  executives
• Emphasis on practical operational issues
• Ownership of process by the members themselves
• Face-to-face discussion of real data with peers
• Multi-disciplinary involvement of staff
• Expect all members to share innovative ideas
• Honour Code to prevent harmful use of data
• Independent, professional analytical support

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Key messages

• Australia has excellent health outcomes
• However, the health system is under intense and
  growing pressure
• Hospitals are at the epicentre of this pressure
• Maintaining our excellent outcomes will require
• Accountable organisations
• Effective leaders
• Peer-to-peer benchmarking assists hospital
  leaders find innovative solutions

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Thank you!For more information

• www.healthroundtable.org.au