Re-configuring health systems? Simple rules define complex systems Steven C. Boyages
Outline <ul><li>Background </li></ul><ul><li>Justification for reconfiguration </li></ul><ul><ul><li>Not meeting the needs...
Background <ul><li>Iodine deficiency disorders in China </li></ul><ul><li>“ cretin” expert </li></ul><ul><li>Population he...
Background cont. C.E.O Chief Endocrine Officer Chief Excitement Officer
Westmead Hospitals
Area Health Services
Dimensions of the new AHS <ul><li>ATLAS (Auburn to Lithgow Area Health Service) </li></ul><ul><li>15,000 staff, 12 major a...
Justification Reconfiguring Health Systems There will be no single right model Public Sector
Challenges in health care <ul><li>Increasing demand, increased expectations </li></ul><ul><li>Increasing costs due to tech...
Health care <ul><li>Cost vs investment </li></ul><ul><li>NSW spends about 28% of budget on health care </li></ul><ul><ul><...
The players in this game <ul><li>Patients </li></ul><ul><li>Providers </li></ul><ul><li>Purchasers (Health Service Deliver...
Health care is a series of transactions <ul><li>Provider to Patient (P2P) </li></ul><ul><ul><li>Business to consumer (B2C)...
The business of health Patient Level Settings of Care Whole system level
Clinical transactions are simple <ul><li>History </li></ul><ul><li>Physical examination </li></ul><ul><li>Tests ordered </...
Business of health Settings of care <ul><li>Work flow is driven by rules that are generally simple </li></ul><ul><li>Wards...
Whole of system The Frog and the Bicylce <ul><li>Organic systems versus engineering systems theory </li></ul><ul><li>Healt...
Justification Reconfiguring Health Systems Where do we start? More money will solve the problem? Restructure?
Understanding flow is the key <ul><li>Health focuses on the compartments </li></ul><ul><li>Tends to isolate, creating isla...
The next wave of reform <ul><li>Logistics </li></ul><ul><li>Supply chain management </li></ul><ul><li>Real time enterprise...
Banking vs Health <ul><li>Customer friendly </li></ul><ul><li>Provides summary and transactional information </li></ul><ul...
Information technology in health  How will it add value?
Health System Benefits (Why?) <ul><li>Improved efficiency, supply chain management </li></ul><ul><ul><li>Corporate and cli...
The main issue <ul><li>Not why health IT? </li></ul><ul><li>Not what should we do? </li></ul><ul><li>But how do we do it? ...
Future Strategy (What?) <ul><li>Patient Information Management Systems are the foundation </li></ul><ul><li>Point of Care ...
Web based technology <ul><li>Allows system integration </li></ul><ul><li>Integrates with legacy source systems </li></ul><...
Examples to date <ul><li>On line incident reporting system (Watcher) </li></ul><ul><li>Patient Navigation Campaign </li></...
 
 
Bed Board - Live Data Screen
 
Current Implementation at WSAHS
Cumberland Data Centre  - View of Racks containing LAN Servers
Managers are from Mars and clinicians are from Venus.
Clinical leadership and Governance <ul><li>Vital to the success of delivering healthcare and improving health outcomes </l...
Quality and patient safety <ul><li>Increasing emphasis </li></ul><ul><li>Embedded into board and operational structures </...
Western Sydney <ul><li>Clinical streaming </li></ul><ul><li>Moved from facility management to program management </li></ul...
Western Sydney <ul><li>Program management </li></ul><ul><ul><li>No hospital CEOs </li></ul></ul><ul><li>3 major CMUs </li>...
Primary Health Organisations <ul><li>Local provider organisations funded by a DHB to provide a specified set of essential ...
Aims of the  Primary Health Care Strategy <ul><li>Better health for all </li></ul><ul><li>Reduced health inequalities </li...
Conclusion <ul><li>Re configuration of health care delivery will be a constant to be able to better target investments in ...
Three envelopes given to a CEO on day 1 <ul><li>First crisis- open envelope 1 </li></ul><ul><ul><li>Action- “Blame the pre...
<ul><li>“ There is nothing more difficult to carry out, no more doubtful of success nor more dangerous to handle, than to ...
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RACMA NZ

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  • Summary of PoCCS progress at WSAHS: Cerner OCF Clinical Repository Radiology Information System (RIS) – Cerner RadNet Pathology – Cerner PathNet Discharge Report Summary (DRS) Emergency Department Information System (EDIS) Picture Archive and Communication System (PACS) Orders Electronic Prescribing Decision Support (EPDS)
  • PHOs are the key mechanism. More about the points in this slide is in the following ones
  • The first two are overall aims for health (New Zealand Health Strategy) Primary Health Care can certainly help reduce health inequalities – see next slide at this point
  • Any change will be difficult Roll out starts immediately, but transition period of some years to achieve 99% clinicians agree with what we are proposing
  • RACMA NZ

    1. 1. Re-configuring health systems? Simple rules define complex systems Steven C. Boyages
    2. 2. Outline <ul><li>Background </li></ul><ul><li>Justification for reconfiguration </li></ul><ul><ul><li>Not meeting the needs of its stakeholders </li></ul></ul><ul><li>The business of health </li></ul><ul><ul><li>Frog and the bicycle </li></ul></ul><ul><ul><li>Bee-hives </li></ul></ul><ul><ul><li>Clinical accountancy </li></ul></ul><ul><li>Information management </li></ul><ul><ul><li>Patient safety </li></ul></ul><ul><ul><li>Access </li></ul></ul><ul><ul><li>Performance </li></ul></ul><ul><li>Technology </li></ul><ul><ul><li>Disruptive technology </li></ul></ul><ul><ul><li>IT </li></ul></ul><ul><ul><li>Wireless </li></ul></ul><ul><ul><li>How to capture value </li></ul></ul><ul><li>Organisational structure </li></ul><ul><ul><li>How to bring it all together </li></ul></ul>
    3. 3. Background <ul><li>Iodine deficiency disorders in China </li></ul><ul><li>“ cretin” expert </li></ul><ul><li>Population health interventions have a greater impact on the health of communities than individual approaches alone </li></ul>
    4. 4. Background cont. C.E.O Chief Endocrine Officer Chief Excitement Officer
    5. 5. Westmead Hospitals
    6. 6. Area Health Services
    7. 7. Dimensions of the new AHS <ul><li>ATLAS (Auburn to Lithgow Area Health Service) </li></ul><ul><li>15,000 staff, 12 major acute care facilities, </li></ul><ul><li>30 community health centres </li></ul><ul><li>6 Divisions of GP </li></ul><ul><li>1.2 million people </li></ul><ul><li>2800 beds </li></ul><ul><li>A$ 1.5 billion dollars per annum recurrent </li></ul><ul><li>A$ 1.5 billion in capital assets </li></ul>
    8. 8. Justification Reconfiguring Health Systems There will be no single right model Public Sector
    9. 9. Challenges in health care <ul><li>Increasing demand, increased expectations </li></ul><ul><li>Increasing costs due to technology, increased life span and aging of the population </li></ul><ul><li>Increasing prevalence of chronic disease </li></ul><ul><li>Islands of health care where the patient acts as the glue in the system </li></ul><ul><li>Workforce shortages </li></ul><ul><li>Focus on patient safety and quality </li></ul><ul><li>High touch-high tech industry, organic growth </li></ul><ul><li>Change management vs change fatigue </li></ul><ul><li>Modernisation strategies required (not reinvention) </li></ul>
    10. 10. Health care <ul><li>Cost vs investment </li></ul><ul><li>NSW spends about 28% of budget on health care </li></ul><ul><ul><li>1.2 million dollars per hour </li></ul></ul><ul><li>In Australia, health care expenditure is 9.3% </li></ul><ul><li>In NZ 8.4% of GDP </li></ul><ul><li>In Hong Kong 5% of GDP </li></ul><ul><li>In the USA, 16-17% of GDP </li></ul><ul><li>How do you slow the rate of health care growth? </li></ul><ul><li>How do you achieve the appropriate balance of investment in population health vs acute care? </li></ul>
    11. 11. The players in this game <ul><li>Patients </li></ul><ul><li>Providers </li></ul><ul><li>Purchasers (Health Service Delivery Units, Retailers) </li></ul><ul><li>Payers (Funders, Wholesalers) </li></ul><ul><li>Politicians </li></ul>
    12. 12. Health care is a series of transactions <ul><li>Provider to Patient (P2P) </li></ul><ul><ul><li>Business to consumer (B2C) </li></ul></ul><ul><li>Provider to Provider, Unit to Unit </li></ul><ul><ul><li>Internal to an organisation </li></ul></ul><ul><ul><li>External to an organisation </li></ul></ul><ul><ul><li>Business to Business (B2B) </li></ul></ul><ul><li>Funder to Purchaser </li></ul><ul><li>The nature of those transactions are constant </li></ul>
    13. 13. The business of health Patient Level Settings of Care Whole system level
    14. 14. Clinical transactions are simple <ul><li>History </li></ul><ul><li>Physical examination </li></ul><ul><li>Tests ordered </li></ul><ul><li>Intervention </li></ul><ul><li>Review </li></ul><ul><li>Appointment </li></ul><ul><li>Bill </li></ul><ul><li>And the cycle repeats itself </li></ul><ul><li>Constant for many centuries </li></ul><ul><li>What elements of the transaction are necessary to document, store and retrieve ? </li></ul><ul><li>When and How </li></ul>
    15. 15. Business of health Settings of care <ul><li>Work flow is driven by rules that are generally simple </li></ul><ul><li>Wards, ER, theatres, Community Health Centres </li></ul><ul><li>Bee-hive model of work </li></ul><ul><li>Important to understand in relation to re-engineering </li></ul>
    16. 16. Whole of system The Frog and the Bicylce <ul><li>Organic systems versus engineering systems theory </li></ul><ul><li>Health is an organic complex system </li></ul><ul><li>Knowledge business </li></ul><ul><li>Generating knowledge, imparting knowledge, applying knowledge </li></ul><ul><li>If the entities of an organic system are not aligned to sustain the organism, it will die; SHARED SERVICES </li></ul>
    17. 17. Justification Reconfiguring Health Systems Where do we start? More money will solve the problem? Restructure?
    18. 18. Understanding flow is the key <ul><li>Health focuses on the compartments </li></ul><ul><li>Tends to isolate, creating islands of care </li></ul><ul><li>Connectivity either physically or in governance is lacking </li></ul><ul><li>Clear business principles lacking </li></ul><ul><li>Incentives are not aligned and in fact perverse incentives abound </li></ul><ul><li>No clear clinical supply chain </li></ul>
    19. 19. The next wave of reform <ul><li>Logistics </li></ul><ul><li>Supply chain management </li></ul><ul><li>Real time enterprise monitoring </li></ul><ul><li>Customer relationship management (CRM) </li></ul>
    20. 20. Banking vs Health <ul><li>Customer friendly </li></ul><ul><li>Provides summary and transactional information </li></ul><ul><li>Available at many points </li></ul><ul><li>No single EFR </li></ul><ul><li>Multiple EFR </li></ul><ul><li>Accounting and governance standards </li></ul><ul><li>Customer hostile </li></ul><ul><li>No summary information </li></ul><ul><li>Available at one point </li></ul><ul><li>Attempting EHR, single vs multiple </li></ul><ul><li>No standards for capturing transactions </li></ul><ul><li>Clinical “accounting” required </li></ul>
    21. 21. Information technology in health How will it add value?
    22. 22. Health System Benefits (Why?) <ul><li>Improved efficiency, supply chain management </li></ul><ul><ul><li>Corporate and clinical </li></ul></ul><ul><li>Improved patient safety </li></ul><ul><ul><li>Redundant systems eg electronic prescription decision support </li></ul></ul><ul><li>Improved information flow </li></ul><ul><ul><li>Electronic health record </li></ul></ul><ul><ul><li>Chronic disease management </li></ul></ul><ul><ul><li>Epidemiological research </li></ul></ul><ul><li>Convergence of genomics and patient information </li></ul><ul><ul><li>Biomedical informatics </li></ul></ul><ul><li>Improved education and training </li></ul><ul><ul><li>Simulation centres </li></ul></ul>
    23. 23. The main issue <ul><li>Not why health IT? </li></ul><ul><li>Not what should we do? </li></ul><ul><li>But how do we do it? </li></ul>
    24. 24. Future Strategy (What?) <ul><li>Patient Information Management Systems are the foundation </li></ul><ul><li>Point of Care Clinical Systems </li></ul><ul><ul><li>Results reporting </li></ul></ul><ul><ul><li>Clinical documentation </li></ul></ul><ul><ul><li>Orders </li></ul></ul><ul><ul><li>Decision support </li></ul></ul><ul><li>Integrate event information </li></ul><ul><ul><li>Discharge Referral System </li></ul></ul><ul><ul><li>EMRs </li></ul></ul><ul><ul><li>Electronic Health Records </li></ul></ul><ul><li>Performance Information </li></ul><ul><ul><li>KPIs </li></ul></ul><ul><li>Electronic information available at the point of care </li></ul><ul><li>Mobility </li></ul><ul><li>Connectivity across the settings </li></ul><ul><li>Security and Authentication </li></ul><ul><li>Balance of clinical and corporate applications </li></ul><ul><li>Web based technology (decoupling) </li></ul>
    25. 25. Web based technology <ul><li>Allows system integration </li></ul><ul><li>Integrates with legacy source systems </li></ul><ul><li>Allows configuration of the system to the needs of the user </li></ul><ul><li>Allows secure connectivity </li></ul><ul><li>Single login, roles based definition </li></ul><ul><li>Health portals </li></ul><ul><li>Real time enterprise monitoring </li></ul>
    26. 26. Examples to date <ul><li>On line incident reporting system (Watcher) </li></ul><ul><li>Patient Navigation Campaign </li></ul><ul><ul><li>Capacity demand office, bed supply </li></ul></ul><ul><li>On line signature verification system </li></ul><ul><li>CEO dashboard </li></ul>
    27. 29. Bed Board - Live Data Screen
    28. 31. Current Implementation at WSAHS
    29. 32. Cumberland Data Centre - View of Racks containing LAN Servers
    30. 33. Managers are from Mars and clinicians are from Venus.
    31. 34. Clinical leadership and Governance <ul><li>Vital to the success of delivering healthcare and improving health outcomes </li></ul><ul><li>Goes beyond clinical engagement or participation </li></ul><ul><li>Partnership with corporate leadership is essential </li></ul><ul><li>Leadership aligns responsibility, authority and accountability </li></ul><ul><li>Clinical governance </li></ul>
    32. 35. Quality and patient safety <ul><li>Increasing emphasis </li></ul><ul><li>Embedded into board and operational structures </li></ul><ul><li>A range of programs available </li></ul><ul><li>Implications for individuals and professional bodies </li></ul><ul><li>Need to develop a coherent set of indicators </li></ul>
    33. 36. Western Sydney <ul><li>Clinical streaming </li></ul><ul><li>Moved from facility management to program management </li></ul><ul><li>All budgets are aligned with structure </li></ul><ul><li>Three major business groups </li></ul><ul><ul><li>Acute care </li></ul></ul><ul><ul><li>Procedural Care </li></ul></ul><ul><ul><li>Chronic and Complex Care </li></ul></ul><ul><li>Learning Martian and Venetian language </li></ul>
    34. 37. Western Sydney <ul><li>Program management </li></ul><ul><ul><li>No hospital CEOs </li></ul></ul><ul><li>3 major CMUs </li></ul><ul><ul><li>17 clinical streams </li></ul></ul><ul><li>Area wide corporate services </li></ul><ul><li>Independent business units </li></ul>
    35. 38. Primary Health Organisations <ul><li>Local provider organisations funded by a DHB to provide a specified set of essential primary health care services to an enrolled population </li></ul>
    36. 39. Aims of the Primary Health Care Strategy <ul><li>Better health for all </li></ul><ul><li>Reduced health inequalities </li></ul><ul><li>More emphasis on population health </li></ul><ul><li>Better access to primary health care services </li></ul><ul><li>Co-ordination, continuity, collaboration </li></ul><ul><li>Community participation </li></ul><ul><li>Primary health care fully involved in health system </li></ul>
    37. 40. Conclusion <ul><li>Re configuration of health care delivery will be a constant to be able to better target investments in health. </li></ul><ul><li>This will necessitate the development of new sets of skills and knowledge facilitated by better systems of information capture, presentation and connection </li></ul>
    38. 41. Three envelopes given to a CEO on day 1 <ul><li>First crisis- open envelope 1 </li></ul><ul><ul><li>Action- “Blame the previous CEO and team for problem” </li></ul></ul><ul><li>Second crisis- open envelope 2 </li></ul><ul><ul><li>Action-Restructure </li></ul></ul><ul><li>Third crisis- open envelope 3 </li></ul><ul><ul><li>Action-Prepare next 3 envelopes </li></ul></ul>
    39. 42. <ul><li>“ There is nothing more difficult to carry out, no more doubtful of success nor more dangerous to handle, than to initiate a new order of things. For the reformer has enemies, in all those who profit from the old order, and only lukewarm defenders in all those who would profit by the new.” </li></ul><ul><li>Niccolo Machiavelli, “The Prince”. 1515 </li></ul>

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