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

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

2. 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

3. 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 1990�s 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

4. The Health Roundtable � An Innovation Clearinghouse 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 The roundtable concept provides a clearinghouse for sharing this expertise amongst a large number of major hospitals. Rather than have each hospital send expeditions out to every other hospital to find new ideas, all take part in discussions of key topics at a central location, and take back the useful ideas to their home hospital. The roundtable concept provides a clearinghouse for sharing this expertise amongst a large number of major hospitals. Rather than have each hospital send expeditions out to every other hospital to find new ideas, all take part in discussions of key topics at a central location, and take back the useful ideas to their home hospital.

5. 34 Organisational Members �over 50 Hospital facilities

6. Australia�s health care system has delivered excellent outcomes �

7. Low & declining infant mortality

8. High & improving life expectancy

9. Lower standardised mortality rate

10. Health Costs 20% Higher than UK - Half of USA

11. A Good Health Care Report!

12. But � can we maintain these outcomes?

13. Ageing of the population

14. Global consumer access to information - aortic aneurysm example

15. New (expensive) treatments

16. Dramatic rise in drug expenses

17. Health Costs growing 6.9% pa - much faster than the economy as a whole

18. Health care now costs $4,000 per person

19. Ageing Workforce

20. Global competition for health workers

21. 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

22. These pressures are focused most acutely on hospitals

23. Pressures on the Health System

24. Expecting 25% growth in elderly (80+) this decade to 3.9% of population

25. Over 80s already 11% of all Patients

26. . . . and 22% of all emergency beddays

27. Elderly use 8 times as many bed days as younger people

28. Pressures on the Health System

29. Robotic Surgery

30. New Knowledge and Technologies Genomics Proteomics Metabolomics Molecular Imaging Nanotechnology Bioinformatics Molecular Therapeutics Molecular Imaging

31. Pressures on the Health System

32. Public Hospital funding share continues to decline � now below 35%

33. Little new overnight bed capacity added to the system in a decade

34. Most growth has been in same-day admissions �

35. � while public hospital bed nights have dropped almost 1% per year

36. Increases in Emergency medical patients have led to reductions in Elective surgical patients

37. � with Emergency patients occupying over 62% of beds, up from 56% in 1996

38. VOLUME PREDICTIONSPredicting the Future is Tricky!

39. Predictions from 1991 predicted 28% fewer bed days than actually used in 2001

40. An additional 1.8 million bed nights (5,000 beds) will be needed by 2011 Due to elderly growth + population growth at current levels of hospital usage ... Creating more strain on public and private hospital systems

41. Alternative is to make dramatic reductions in elderly length of stay

42. Pressures on the Health System

43. Medical Workforce Example

44. Nursing Workforce Example

45. �We have met the enemy, and he is us�

46. Our own worst enemy ... 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

47. Every system is perfectly designed to produce the results it gets.(D. Berwick)

48. How to Improve Effectiveness? Accountable Organisations Effective Leaders

49. Accountable Organisations required in a rapid change environment Clear Goals Clear Accountability for Results Agreed Resources Delegated Responsibility Long-term Vision

50. Accountable Organisations

51. Resource Centre Managers

52. Resource Centre Building Blocks Clear accountability Clear task definition Clear output expectation Clear output measurement Rapid feedback Single source of funds Clear operational plan

53. Devolution of decision making 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

54. Resource Centre structure allows views from multiple directions

55. Long-term Vision & Tenure Required to Manoeuvre the Healthcare Supertanker Elliott Jaques research in 1970�s and 80�s Major Facility Managers need ability to plan 5-10 years ahead Health System Leaders need ability to plan 10-20 years ahead

56. 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

57. We have no shortage of national priorities � 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.

58. � but little translates to the actual health care agreements with States � �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.�

59. � �provide free access within clinically appropriate period� �

60. States differ in how accountability and responsibility flow to hospitals Victoria � Regional health boards NSW � Area health services Queensland � Zones and Districts WA � Regional health boards SA � Metropolitan regions NZ � District Health Boards

61. Victoria and New Zealand appear to have more efficient systems

62. Leadership is a key issue: Average tenure at the top only 2.5 years

63. The Health Roundtable Role Explore key issues affecting hospitals Analyse benchmarking data with trusted peers Encourage short-cycle improvement projects Provide peer support

64. Benchmarking for Innovations � Voluntary comparisons Search for differences Data Methods Clinical Practices Accept �approximate� data No �right or wrong� Opportunity focus Gradual fine-tuning

65. �Not for Accountability to Government Mandated Uniform Tightly defined Score � �win/lose� Denial �by losers� Gaming the system �Inspectors� needed

66. 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!)

67. Case Study 1: Laparoscopic Cholecystectomy

68. �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

69. Case Study 2: Hip Revision or Replacement

70. �Good Practices� Interview of FacilityHip Revision or Replacement

71. Knowledge of differences only the first step in diffusion of innovative ideas

72. We use Roundtable discussions to share ideas and promote action

73. Other Innovations Spread by The Health Roundtable

74. 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

75. 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

76. Thank you!For more information: www.healthroundtable.org.au