2005 Review by David Dean, General Manager

1. 2005 Reviewby David Dean, General Manager Harbourview Hotel, North Sydney 15 November 2005

2. Happy 10th Anniversary!

3. Agenda – 15 November

4. The Health Roundtable:An Innovation Clearinghouse • Share problems • Share solutions • Avoid reinventing wheels • “Seed” large scale projects • Provide CEO network Health Roundtable UHC IHI

5. 36 Organisational Members –over 50 Hospital facilities Plus: Regional Health Improvement Network

6. The Health Roundtable Team • Michael Hart – Data Processing Analyst • Duncan Stuart – Clinical Consultant • Bindy Krantis – Report Preparation • Peter Reeves – Operational Consultant • Margaret Dean – Accounts Administrator • Pieter Walker – Operational Consultant • Nick Smeaton – Website Administrator • Fabian Chessell – Project Manager

7. Overview • Look back & review progress since 1995 • Update patient service goals • Identify today’s barriers to reaching goals • Share existing innovations that remove barriers • Seed ideas for innovation-sharing in 2006

8. Our Origins • Major hospital reviews in 1989-93 highlighted major operational issues, but were expensive and confronting to staff • Approaches to Federal Government in 1993/94 for assistance in developing “best practice” failed on cost and selectivity • Information Technology “solutions” promised huge operational improvements but failed to deliver • Approach by CSC Australia in mid-1995 to Alfred Hospital led to seed funding for process to identify “good practice” • Seven hospitals invited to participate in first meeting

9. Key Design Principles(Based on avoiding what didn’t work!) • 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

10. Inaugural Health Roundtable“How to get patients into and out of high-occupancy hospitals while maintaining high quality patient care” Subtitle: “Removing the Rocks”

11. The Inaugural Health RoundtableNovember 1995Mona Vale Conference Centre

12.       Usually Met  Improving  Struggling Patient Service Goals for 1996

13.       Usually Met  Improving  Struggling Patient Service Goals for 1996

14. Major Barriers to Reach Goals • Emergency Patient Barriers • Elective Patient Barriers • Day of Surgery Admission Barriers • Discharge Planning Barriers • Primary Care Coordination Barriers

15. Major Barriers Identified • Emergency Patient Barriers • Delays in deciding whether to admit • Shortage of inpatient beds • Bottlenecks at internal interfaces between ED, ICU, Wards, Labs • Bottlenecks at external interfaces with Ambulance, Psych, Primary Care, Nursing Homes • Lack of timely information on bed status

16. Major Barriers Identified • Elective Patient Barriers • Unpredictable capacity for elective patients • Difficulty coordinating surgeons & anaesthetist schedules • Inappropriate priority-setting & queue jumping • Perverse incentives blocking efficient treatment of elective patients (capped supply) • Lack of management of waiting lists

17. Major Barriers Identified • Day of Surgery Admission Blockers • Mistrust of anaesthetic assessment by others • Lack of peri-operative facilities for day-of-surgery arrivals • Lack of alternative accommodation for country patients • Lack of time for patient assessment prior to admission • Inability to measure DOSA episodes

18. Major Barriers Identified • Discharge Planning • Lack of coordination of care within hospital • Lack of post-acute carers at home • Delays in Nursing Home placement • Lack of data to flag discharge readiness

19. Major Barriers Identified • Primary Care Coordination • Unknown primary care provider • No financial incentives for GP involvement • Lack of timely info to GP • Mismatch bed allocation to community needs • Lack of coordination of services with primary care / secondary care / nursing homes • Difficulty balancing seasonal changes in emergency / elective demand

20. What has changed since 1995?

21. Innovations Spread by The Health Roundtable

22. More, shorter, inpatient episodes due to fewer bed days available Source: Analysis9495-0405.xls – 8 hospitals with continuous data

23. Average age rising for patients with chronic diseases, but no change in onset for other conditions Source: Analysis9495-0405.xls – 20 hospitals with continuous data

24. Major breakthroughs in treatment in some areas, such as cataract lens procedures … Source: Analysis9495-0405.xls – 20 hospitals with continuous data

25. …and coronary artery interventions, with 177% growth in volume Source: Analysis9495-0405.xls – 8 hospitals continuous data

26. Most DRGs show gradual reduction in LOS, although some hospitals have dramatically different approach Source: Analysis9495-0405.xls – 8 hospitals continuous data

27. Day of Surgery Admission Rates have risen steadily, but still find resistance at some hospitals Source: Analysis9495-0405.xls

28. New Issues

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

30. . . . who already consume 22% of all emergency bed days

31. Drug expenses are rising dramatically

32. Our workforce is ageing… US example Source: http://bhpr.hrsa.gov/healthworkforce/reports/rnproject/report.htm

33. … and we are facing major global competition for health workers USA alone – short 500,000 nurses http://bhpr.hrsa.gov/healthworkforce/reports/rnproject/report.htm#chart1

34. Health system leadership is a key issue with average tenure only 2.5 years

35. Exciting, but very expensive new technologies are arriving http://www.cts.usc.edu/rsi-davincisystem.html

36. However, Public Hospital funding share continues to decline – now below 35%

37. Little new overnight bed capacity has been added to the system in a decade Source: AIHW Hospital Statistics, Table 2.3

38. Increases in Emergency medical patients have led to reductions in Elective surgical patients Emergency up 600 beds Elective down 760 beds Source: HRT, Bed Occupancy.xls

39. … with Emergency patients occupying over 62% of beds, up from 56% in 1996 Source: HRT, Bed Occupancy.xls

40. Australia Predictions Effects of ageing and population growth likely to require 5,000 more beds by 2011 or 6% reduction in bed nights, just to maintain current service levels

41. Summary

42. Key Issues in 1995 • Inadequate hospital funding • Commonwealth / State role overlap • Overuse of hospitals vs primary care • Lack of integrated info technology • Rigid working conditions / demarcations

43. Key Issues in 2005 • Inadequate hospital funding • Commonwealth / State role overlap • Overuse of hospitals vs primary care • Lack of integrated info technology • Rigid working conditions / demarcations • Ageing population and workforce • Rapid growth of new technologies • Lack of long-term leadership

44. Problem is not in the goals Reality Goals • Universal access • First class quality • Improved health outcomes • Long queues • Unacceptable error rate • Measuring activity not outcomes Translationof goalstoaction It is in translating goals into action

45. Key message in 1995 still true today • There are no “magic bullets” • Money is necessary, but not sufficient • We can make better use of the money already provided • Micro-level understanding is required to achieve success in macro-level policy implementation -- “removing the rocks” is still important • We can learn more from each other than we can learn separately

46. Next Steps • Update patient service goals for 2000 • For acute patients • For chronic care patients • Identify today’s barriers to reaching goals • Share existing innovations that remove barriers • Seed ideas for innovation-sharing in 2006