racma nz
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Re-configuring health systems?
Simple rules define complex systems
Steven C. Boyages
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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
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Background
Iodine deficiency disorders in China
“cretin” expert Population health
interventions have a greater impact on the health of communities than individual approaches alone
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Background cont.
C.E.O
Chief Endocrine Officer
Chief Excitement Officer
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Westmead Hospitals
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Area Health Services
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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
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Justification
Reconfiguring Health Systems
There will be no single right model
Public Sector
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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)
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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?
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The players in this game
Patients Providers Purchasers (Health Service Delivery Units,
Retailers) Payers (Funders, Wholesalers) Politicians
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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
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The business of health
Patient Level
Settings of Care
Whole system level
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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
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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
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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
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Justification
Reconfiguring Health Systems
Where do we start?
More money will solve the problem?
Restructure?
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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
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The next wave of reform
Logistics Supply chain management Real time enterprise monitoring Customer relationship management (CRM)
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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
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Information technology in health
How will it add value?
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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
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The main issue
Not why health IT? Not what should we
do? But how do we do it?
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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)
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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
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Examples to date
On line incident reporting system (Watcher) Patient Navigation Campaign
Capacity demand office, bed supply On line signature verification system CEO dashboard
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Bed Board - Live Data Screen
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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
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Cumberland Data Centre - View of Racks containing LAN Servers
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Managers are from Mars and clinicians are from
Venus.
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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
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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
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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
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Western Sydney
Program management No hospital CEOs
3 major CMUs 17 clinical streams
Area wide corporate services
Independent business units
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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
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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
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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
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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
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“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