Four Key Lessons in Improving Health Care Service Delivery - Personal observations from The Health Roundtable Experience

Four Key Lessons in Improving Health Care Service Delivery Personal observations from The Health Roundtable Experience David Dean, PhD General Manager HINZ – 16 October 2008

The Health Roundtable … An Innovation Clearinghouse

Non-profit membership group

53 Members

107 Facilities

Founded 1995

Share problems

Share solutions

Provides informal network

Health Roundtable

NZ Members – All 21 District Health Boards

External Pressure Why a Roundtable? Health Sector Knowledge & Technology Professional Work Rules Government Policy Ageing Population

Speed adoption of innovative ideas 2. Listen to Peers 1. Identify Differences 3. Decision 3. Make Decision 4. Test Changes 5. Measure Improvements The Roundtable Coping Process:

Innovation Benchmarking

Voluntary comparisons

Self-help focus

Search for differences

Data Methods

Clinical Practices

No “right” or “wrong”

Gradual fine-tuning

Not Accountability Benchmarking

Annual data analysis to identify differences

3 million inpatient episodes

2 million emergency presentations

4 million allied health interventions

Analysis by DRG, Discharge Unit, Clinician

Relative stay index

Complications of care, readmission rate

Standardised mortality rate

Specialty benchmarking: maternity, nursing, mental health, allied health, imaging, costing

Program for 2008

Now 13 Years Old! – A Teenager Four Key Lessons

1. “Out of sight, out of mind” Four Lessons

Casemix averages hide big differences! Out of sight, out of mind

Hospitals differ in patient mix Out of sight, out of mind Apples Carrots Eggplants

Deeper analysis uncovers “real” leaders Out of sight, out of mind

Health Roundtable Relative Stay Index

Compares actual with “expected” length of stay for each episode based on:

Diagnostic Related Group (DRG)

Patient Age Group (6 groupings)

Emergency / Elective Status

Admission Source (Regular / Transfer in)

Discharge Destination (Home, Died,Trf, Other)

Co-morbidity Status (3+ diseases, <3)

Over 8000 patient subgroups used to calculate expected LOS

RSI helps to highlight real differences

Day of Surgery Admission (DOSA) target set in 1996 Out of sight, out of mind 70% “Good practice” target

Recently Added Key Performance Indicators

Death Audits: Standardised Mortality Rates

Emergency Waiting Times: Entry  Bed

Clinical Indicators: % INR test readings > 5

Staffing Indicators: “Gen Y” Turnover Rate

Out of sight, out of mind

2. “Money Talks” Four Lessons

Casemix payment incentives work! 2003/2004 average = 100% “ Money talks”

Creativity used to find extra funding “ Money talks”

Practices change as funding changes “ Money talks”

Which service would you choose?

24 / 7 availability

Full service range at same location

Free!

Requires wait of four to six hours

(Will involve trainees)

9 to 5 availability

Many separate scattered services

Pay $$

Requires wait of 2-3 days for first visit and weeks for specialist attention

“ Money talks”

Key Messages

“Measure what you need to manage”

Count all patient services delivered

Drop distinction between “inpatient” and “outpatient,” “private” and “public”

Measure duration in hours, not days

Track funding source separately

Consider consequences of pricing systems on behaviour

“ Money talks”

3. “Necessity is the Mother of Invention” Four Lessons

Elderly population growing 30% this decade “ Necessity…”

Elderly use 8 times as many bed days as younger people “ Necessity…”

However, Australia has less public overnight bed capacity than 10 years ago Source: AIHW Hospital Statistics, Table 2.3 “ Necessity…”

Australia must build and staff an extra 7000 beds by 2011…

(Due to elderly growth + population growth at current levels of hospital usage)

Source: AIHW, ABS, Chappell Dean analysis – same-day stays excluded from calculations “ Necessity…” … or reduce elderly bed demand by 4+% per year

Some of the strategies our members have developed to address bed shortages

DOSA

Medical Assessment Planning Units

Hospital in the Home

Hospital in the Nursing Home

Frequent Attender Programs

Primary Options for Acute Care

Shift to Ambulatory Care

Redesigning Patient Journey

“ Lean Healthcare”

“ Necessity…”

Staff Interactions to Discharge Patient to Sub-Acute Care

Recent Member Initiatives

Decreased Diabetes referral time from 6 months to 1 day (NZ)

Reduced maximum patient waiting time on day of elective surgery to less than 3 hours (NZ)

Reduced theatre cancellations to zero (QLD)

Reduced waiting time for sub-acute bed by 3.3 days (VIC)

Discharged 67% of medical patients by 11am (SA)

Reduced urgent biochemistry turnaround time by 30% (QLD)

Key Message: Improvements are driven by first-line staff – who see value in reducing wasted time and effort in the system

4. “Misery Loves Company” Four Lessons

Members value the opportunity to share problems and innovations with peers

Confidential “self-help” discussions

Action orientation

Monitor progress on key projects over time

Nurturing informal peer networks

2008 Roundtables

Improving patient journey through imaging services

Improving interface between acute & subacute

Reducing in-hospital mortality rate

Improving clinical management systems

“ Misery loves company” “ Great opportunity to hear innovative ideas and network with people working in the same area, with similar problems ” – Feedback Comment, 2008

Four Lessons Summary