Re-configuring health systems?

Simple rules define complex systems

Steven C. Boyages

Outline Background Justification for reconfiguration

Not meeting the needs of its stakeholders

The business of health Frog and the bicycle Bee-hives Clinical accountancy

Information management Patient safety Access Performance

Technology Disruptive technology IT Wireless How to capture value

Organisational structure How to bring it all together

Background

Iodine deficiency disorders in China

“cretin” expert Population health

interventions have a greater impact on the health of communities than individual approaches alone

Background cont.

C.E.O

Chief Endocrine Officer

Chief Excitement Officer

Westmead Hospitals

Area Health Services

Dimensions of the new AHS

ATLAS (Auburn to Lithgow Area Health Service) 15,000 staff, 12 major acute care facilities, 30 community health centres 6 Divisions of GP 1.2 million people 2800 beds A$ 1.5 billion dollars per annum recurrent A$ 1.5 billion in capital assets

Justification

Reconfiguring Health Systems

There will be no single right model

Public Sector

Challenges in health care

Increasing demand, increased expectations Increasing costs due to technology, increased life span and

aging of the population Increasing prevalence of chronic disease Islands of health care where the patient acts as the glue in the

system Workforce shortages Focus on patient safety and quality High touch-high tech industry, organic growth Change management vs change fatigue Modernisation strategies required (not reinvention)

Health care

Cost vs investment NSW spends about 28% of budget on health care

1.2 million dollars per hour In Australia, health care expenditure is 9.3% In NZ 8.4% of GDP In Hong Kong 5% of GDP In the USA, 16-17% of GDP How do you slow the rate of health care growth? How do you achieve the appropriate balance of

investment in population health vs acute care?

The players in this game

Patients Providers Purchasers (Health Service Delivery Units,

Retailers) Payers (Funders, Wholesalers) Politicians

Health care is a series of transactions

Provider to Patient (P2P) Business to consumer (B2C)

Provider to Provider, Unit to Unit Internal to an organisation External to an organisation Business to Business (B2B)

Funder to Purchaser The nature of those transactions are constant

The business of health

Patient Level

Settings of Care

Whole system level

Clinical transactions are simple

History Physical examination Tests ordered Intervention Review Appointment Bill And the cycle repeats

itself

Constant for many centuries

What elements of the transaction are necessary to document, store and retrieve ?

When and How

Business of healthSettings of care

Work flow is driven by rules that are generally simple

Wards, ER, theatres, Community Health Centres

Bee-hive model of work Important to understand

in relation to re-engineering

Whole of systemThe Frog and the Bicylce

Organic systems versus engineering systems theory Health is an organic complex system Knowledge business Generating knowledge, imparting knowledge, applying knowledge If the entities of an organic system are not aligned to sustain the

organism, it will die; SHARED SERVICES

Justification

Reconfiguring Health Systems

Where do we start?

More money will solve the problem?

Restructure?

Understanding flow is the key

Health focuses on the compartments Tends to isolate, creating islands of care Connectivity either physically or in

governance is lacking Clear business principles lacking Incentives are not aligned and in fact

perverse incentives abound No clear clinical supply chain

The next wave of reform

Logistics Supply chain management Real time enterprise monitoring Customer relationship management (CRM)

Banking vs Health

Customer friendly Provides summary and

transactional information

Available at many points

No single EFR Multiple EFR Accounting and

governance standards

Customer hostile No summary

information Available at one point Attempting EHR, single

vs multiple No standards for

capturing transactions Clinical “accounting”

required

Information technology in health

How will it add value?

Health System Benefits (Why?) Improved efficiency, supply chain management

Corporate and clinical Improved patient safety

Redundant systems eg electronic prescription decision support Improved information flow

Electronic health record Chronic disease management Epidemiological research

Convergence of genomics and patient information Biomedical informatics

Improved education and training Simulation centres

The main issue

Not why health IT? Not what should we

do? But how do we do it?

Future Strategy (What?) Patient Information Management

Systems are the foundation

Point of Care Clinical Systems Results reporting Clinical documentation Orders Decision support

Integrate event information Discharge Referral System EMRs Electronic Health Records

Performance Information KPIs

Electronic information available at the point of care

Mobility

Connectivity across the settings

Security and Authentication

Balance of clinical and corporate applications

Web based technology (decoupling)

Web based technology

Allows system integration Integrates with legacy source systems Allows configuration of the system to the

needs of the user Allows secure connectivity Single login, roles based definition Health portals Real time enterprise monitoring

Examples to date

On line incident reporting system (Watcher) Patient Navigation Campaign

Capacity demand office, bed supply On line signature verification system CEO dashboard

Bed Board - Live Data Screen

Current Implementation at WSAHS

OCFClinical

RepositoryRadNet

Laboratories Im ag ing D ietaryP harm acyC lin ica lM easures(E C G , E E G )

Ancillary(C hap la in ,In terpre ter e tc )

A lliedH ealth

C onsulta tion(D octorN urse)

Laboratories Im ag ing D ietaryP harm acyC lin ica lM easures(E C G , E E G )

Ancillary(C hap la in ,In terpre ter e tc )

A lliedH ealth

C onsulta tion(D octorN urse)

Clinical Pathway/ Care PlanClinical Pathway/ Care Plan

Assessment Charting Progress Notes

TreatmentProtocols

Discharge Referral

ClinicalReports

MedicalAlerts

PatientAcuity

Clinical Pathway/ Care PlanClinical Pathway/ Care Plan

Assessment Charting Progress Notes

TreatmentProtocols

Discharge Referral

ClinicalReports

MedicalAlerts

PatientAcuity

ClinicalDocumentation

DischargeReferral

System (DRS)

PoCCS Phase 1-Order

Management

PoCCS Phase 2-Clinical

Documentation

Neurology :- Clinical Measurements- EEG

WSAHSCurrent

Implementation

Diagnostic Orders & Results

- CV RAMP Stage 1- Cancer Services (Stage 1) outpatient & encounters- Respiratory Care Ambulatory Clinic Sleep Lab

PathNet Millenium- CV Ramp Stage 2- Cancer Serv ices Stage 2

- Interpreter Serv icesReplacement Sy stem

WSAHSFuture

Implementation

DiagnosticReporting

PatientCare

Service Orders

- Stage 1: Implementation Mode

PathNet Classic(v ia OCF f or results

v iewing)

- CV RAMP Stage 1- Cancer Services (Stage 1) outpatient & encounters- Respiratory Care Ambulatory Clinic Sleep Lab

Cumberland Data Centre - View of Racks containing LAN Servers

Managers are from Mars and clinicians are from

Venus.

Clinical leadership and Governance

Vital to the success of delivering healthcare and improving health outcomes

Goes beyond clinical engagement or participation Partnership with corporate leadership is essential Leadership aligns responsibility, authority and

accountability Clinical governance

Quality and patient safety

Increasing emphasis Embedded into board and operational

structures A range of programs available Implications for individuals and professional

bodies Need to develop a coherent set of indicators

Western Sydney

Clinical streaming Moved from facility management to program

management All budgets are aligned with structure Three major business groups

Acute care Procedural Care Chronic and Complex Care

Learning Martian and Venetian language

Western Sydney

Program management No hospital CEOs

3 major CMUs 17 clinical streams

Area wide corporate services

Independent business units

Primary Health Organisations

Local provider organisations funded by a

DHB to provide a specified set of essential

primary health care services to an enrolled

population

Aims of the Primary Health Care Strategy

Better health for allReduced health inequalitiesMore emphasis on population healthBetter access to primary health care servicesCo-ordination, continuity, collaborationCommunity participationPrimary health care fully involved in health system

Conclusion

Re configuration of health care delivery will be a constant to be able

to better target investments in health.

This will necessitate the development of new sets of skills and

knowledge facilitated by better systems of information capture,

presentation and connection

Three envelopes given to a CEO on day 1

First crisis- open envelope 1 Action- “Blame the previous CEO and team for

problem”

Second crisis- open envelope 2 Action-Restructure

Third crisis- open envelope 3 Action-Prepare next 3 envelopes

“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.”

Niccolo Machiavelli, “The Prince”. 1515