Systems need to be fixed to drive real efficiency in healthcare

Gold Coast Hospital hit the headlines last year as they rolled out their Patient Admission Prediction Tool mapping tool to predict the number of schoolies expected to hit the emergency department over summer week.

However, the benefits of the tool stretched beyond the school break with the CSIRO Australian e-Health Research Centre’s chief executive David Hansen saying* it could save Queensland hospitals up to $23 million per year through improved efficiency from being able to plan ahead with a good degree of accuracy.

The CSIRO Australian e-Health Research Centre developed the software together with Queensland Health, Griffith University and the Queensland University of Technology.

Ahead of his presentation at Workforce Efficiency in Healthcare, I recently caught up with James Lind, Former Director of Access and Patient Flow at the Gold Coast Hospital to see how tools like this fit into the bigger challenge in healthcare to drive efficiency. He explained that many hospitals are still just focusing on the individual targets rather than looking at the bigger picture.

“The hospital wasn’t performing as it should, particularly the emergency department which is why we looked to redesign in the first place.

“The predictor feature is actually just a tool which every other business uses, the accountability frameworks and the meeting structures that you integrate those tools into to get the desired behavioural results – that’s where we’ve done most of our work.

“Data is really the currency by which we argue. The interpretation is the tricky bit and the devil’s in the detail of what data is or isn’t measuring. Once you’ve got over those few hurdles, you can actually use the data powerfully to understand what the issues are.”

Impressively, the team at the GCH managed to reinforce the governance structure by securing the attendance of the CEO in a weekly operational meeting:

“The meetings are designed around using these tools so we’re able to reinforce the behaviours that need to occur. When you say it’s going to be here next week then something occurs as opposed to doesn’t occur. A lot of that comes down to accountability in governance frameworks. Having the CEO in the weekly operational meeting absolutely reinforces the governance structure. The CEO is going be made or broken by the targets, if they don’t make their targets then they’re going to be fired, so there’s a real need for them to be there too,” explained James.

There’s no doubt that the team has made some real progress:, in the two to three years since they’ve been fixing the system and following the data, there’s been a huge improvement in performance results. Last year the hospital finished within 1 per cent of the NEAT target set – quite an improvement considering Gold Coast Hospital was rated worst in the state just a couple of years ago.

Matching KPIs

A key part to the improvements has been developing a set of KPIs that encompasses the system as a whole, rather than individual figures. James broke down the key to successful measurement:

“If you say you’ve made your NEAT, NEST and budget – if you didn’t achieve another KPI it would be looked at as more of a misdemeanour, and some of them are actually contradictory.

“If you fix the system itself though, the KPIs will flow with the system. If you just try and fix a number it won’t work.

“KPIs have to be easily measurable, even ones that seem a bit trickier to measure. Take satisfaction as an example, sometimes you have to pick surrogates of that, (a surrogate of how an ED works could be the ‘did not wait’ (DNW) rate.) You’ve got to have a combination and look in different dimensions with quality indicators, performance indicators and time indicators.

“Hospitals are complex adaptive systems, if you change one variable all the others will change in turn. The problem is you never know whether it’s good or bad as all the variables aren’t always measured.”

Where next

James has now been seconded by another hospital to implement some of the work from the Gold Coast and insists there are key principles that can make a wholesale difference to efficiency:

“A lot of systems are very similar to each other. The mathematics shows that everything is uniquely the same although people will tell you they’re different, and therefore the problems and the solutions by and large have got the same sort of flavours to them, they’re in slightly different quantities and proportions, but they have the same similar makeup.

Many are still not fixing the systems – more just making a number and hoping it will all to go away.”

So where to from here? In one word, NEST. The team are currently going through their ‘myth busting’ stage, looking at the mathematics of the state to work out the simple things first. For example, long case V start case timing and Smart Scheduling.

*See more:

Accelerated design for new hospital – check out how it’s done.

In the run-up to Health Facilities Design and Development conference, I wanted to explore some of the new case studies on the agenda.

One topic that really stood out is Jeffrey Williams’ presentation in his role as Director of Nursing at St John of God Midland Public and Private Hospitals, in particular the short time it took to get the project off the ground.

I caught up with Jeffrey recently when he gave me a sneak preview on some of the features of the new hospitals, key design innovations and a breakdown of the user group consultation process:

Project overview

Construction of the new 367-bed co-located public and private hospitals has reached 70 per cent, and is on target for a November 2015 opening.

With 307 beds, the public hospital will offer a wide range of services to the communities of Perth’s northern and eastern suburbs and the inner Wheatbelt, while the 60-bed integrated private hospital will offer the choice of private health care.

State and Commonwealth Governments have jointly invested $360 million in the public hospital project that will be operated by St John of God Health Care under a public private partnership agreement. The WA-based private health care operator is investing $70 million in the private hospital.

Fast facts

  • First major hospital facilities to be built in the Midland area in more than 50 years.
  • HASSELL architects and Brookfield Multiplex are the design and construction partners.
  • The public hospital will treat approximately 29,000 inpatients, 55,000 emergency patients and 89,000 outpatients in its first full year of operation.
  • The public hospital will provide an expanded range of services from those provided by Swan District Hospital free of charge to public patients.
  • There will be 367 beds in total – 307 public beds and 60 private beds.
  • The public hospital will have 50 per cent more beds than the Swan District Hospital.
  • More than 1,000 staff will be employed at the hospitals.
  • Easy access will be provided for pedestrians, vehicles, and public transport.
  • On-site parking will include 725 staff bays and 221 visitor bays.
  • Easy drop off and access to the emergency department will be provided.
  • Patients, visitors and the community will enjoy landscaped gardens, courtyards, public art and plazas.
  • The hospitals are being built on an eight-hectare site, four times the size of the Midland Oval.

Accelerated design

The State Government released its expression of interest in September 2010 seeking responses within five weeks.

Post EOI submission, St John of God Health Care continued to work closely with its partners Brookfield Multiplex and HASSELL to develop a design within the allocated budget while awaiting confirmation of our selection to tender for the request for proposal.

Thankfully St John of God Health Care was selected and had a short 20-week window in which to prepare and submit a response.

On 1 December 2011, St John of God Health Care was announced as the preferred tenderer and, following negotiations, signed a contract with the Western Australian Government on 14 June 2012.

During the negotiation phase, St John of God Health Care, Brookfield Multiplex and HASSELL worked closely with the State Government’s consultants to ensure that any major design issues were dealt with at a high level so that construction could start as soon as possible after contractual completion.

This preparation allowed St John of God Health Care to achieve the State Government’s goal of starting work within one month of satisfying the conditions precedent, in August 2012

User group design

While we completed the design very quickly, we could only establish the design user groups after the contract was signed. This led to a concurrent construction and user consultation process that meant we had to focus on those areas where we needed to finalise the design and start building first.

We began a four-step user group process, with each group running between 16 and 20 weeks.

At the first meeting, we presented the users with a schematic design. The architects and builders then took the users’ advice and presented the modified design at the second meeting. The third stage was detailed design when we presented drawings showing room elevations and the position of furniture and equipment. The fourth meeting was a presentation of the final detailed design and allowing the users a last opportunity to highlight any remaining issues.  The detailed design was then signed off ready for construction drawings to begin.

Taking the Emergency Department User Group as an example, the users told us that the waiting room was too small and so we adapted the design accordingly. This process allowed us to drill down into the operational detail by asking them their opinion on matters such as the number of cubicles and the department’s layout.

Accelerated construction

While the user group consultations were taking place, preparatory construction work, such as piling and pouring concrete for the floors got underway. We also made decisions such as the location of wet areas to enable holes to be drilled for the later installation of pipes and drainage.

In those early days, we included around 130 square metres of expansion space on each floor. This built-in flexibility meant that we were well prepared for short-and long term expansion and design changes.

Managing expectations

From the word go, we made it clear to the user groups that the construction budgets were fixed.

The WA Health Clinical Services Planning Framework was a useful tool as some things were a given and did not need to be included in the design discussion.

For example, we had already made sure that we had the right number of beds and could explain to the users that we were working with a 30-bed medical ward, a 24-bed short stay surgical unit, or a 12-bed intensive care unit.  We also knew that St John of God Midland Public Hospital was a Level 4 hospital for cardiology and a Level 1 hospital for intensive care.

We were therefore clear about what we were trying to achieve and this allowed the users to understand the clinical scope so they could focus on how the unit might work and how we could make workflow more efficient.

Innovation in design

We standardised all of the rooms that are common across multiple areas of the hospital. For example, a dirty utility and a clean utility have the same layout in all areas.

We will be using swipe access widely throughout the hospitals for security, including to high traffic areas such as emergency department and restricted areas such as drug rooms.

All patient bedroom ensuite rooms were manufactured offsite as ‘pods’ to a standard, including a standard bedroom pod and a mental health pod, and installed within a short timeframe. While this was cost neutral from a construction perspective, cost and time savings were achieved in the installation.

We decentralised our staff stations, meaning that most ward areas have two or three staff stations instead of one centralised staff station and so clinicians will be closer to their patients.

Finally, we designed to accommodate future expansion. When the State Government issued its proposal for a 307-bed public hospital, they said that the hospital must have the capability to expand to 464-beds by 2021.

The design accommodates expansion in several ways:

1. Intensive Care Unit and Coronary Care Unit

This 12-bed shared unit has six rooms configured for intensive care patients and six rooms configured for coronary care patients. The six coronary care rooms can quickly be converted to intensive care rooms as the required services are already in place and space exists in the adjacent area for 12 coronary care beds to be installed with minimal disruption.

2. Operating theatres suite

The operating theatres suite is designed to cater for the maximum 464-bed capacity with nine theatres and three procedure rooms. These are all of equal size and configuration meaning that the three procedure rooms can easily be converted into theatres, while the procedure rooms can be re-located to a nearby area of the hospital.

3. Private beds

The two 30-bed private wards have been integrated in such a way that when the State Government wants to expand the public hospital from 307 to 367 beds, these can easily be converted into public hospital beds and St John of God Health Care will build a stand-alone private hospital on a nearby site.

4. Additional wing

The expansion to 464-beds can be achieved by adding a new wing extending out from the existing ward block on the northern side of the hospital. Again, this is designed to be achieved with minimal disruption to existing hospital operations.

Lessons learnt

I have two roles and two sets of responsibilities on this project: the first is clinical design and the second is transition and operational readiness. I have learnt lessons across both of these areas.

It was challenging in terms of the limitations on which people within WA Health that we and the other tenderers were allowed not access during the bid preparations. If we were to go through the same process in the future, we would request earlier and wider access to key players in the public sector.

Secondly, we would focus on operational preparedness earlier. While we had a firm view of how we would run the hospital, we did not start working through this in earnest until after the building program started. If we had begun earlier, we would have benefited from additional preparation time.

However, all aspects of the project, including the partnership with WA Health and the North Metropolitan Health Service, in particular, have worked really well. In terms of construction and commissioning, everything is on budget and on track for opening in November 2015

Working in partnership

The traditional public private partnership means the State saves on design, construction and facility management, but continues to deliver the service. As our model also includes clinical services delivery, the State Government can achieve further efficiencies.

Overall, it has been a very positive process, with the focus now firmly on completing construction, operationalising our commissioning program and finalising the details of the patient transfer from the existing Swan District Hospital that will close when the new hospital opens.

Hear more from Jeffrey during his presentation at Health Facilities Design and Development Victoria.

5 questions that will make or break Australian Healthcare

I’ve been working in the Australian healthcare industry for a few years now, and in all honesty, it’s slow progress. When it comes to tackling the critical long term challenges to fix some major holes in the healthcare system, it starts from the ground up.

During Australian Healthcare Week 2014, we thought it was time to get some of the Australian healthcare leaders in a room to discuss some of the key burning questions on everyone’s lips.

Several clear areas stood out, so here they are – the five questions that everyone in healthcare should be thinking about to revolutionise our system and drive real positive change.

So who was involved?

  • Leonie Hobbs, Senior Consultant, Carramar Consulting
  • Kathy Campbell, ICT Manager, VCCC
  • Rob Clarke, WSP Independent
  • David Johnston , eHealth Consultant,
  • Claire GrooMbridge, Facility Planner, Hunter New England Local Health District
  • Sandra Roggeveen, CEO, Dzhon
  • Stanton Kroenert, Manager, Woods Bagot
  • Damien Crough, Business Development Manager, Hickory Group
  • Ian Mitchell, Principal, Conrad Gargett Riddel
  • Don Garner, Group Leader – Health, Sinclair Knight Merz
  • John Goodchap, National Manager – Health, Hansen Yuncken
  • Steve Trevenar, Head of Business & Strategy Healthcare & Scientific Research, Lend Lease
  • Debra Barbas, Clinical Services Manager, St John of God Murdoch Hospital
  • Rohan Wilson, Architectural Director, DesignInc
  • Mark Halpin, Director – Infrastructure Management, The Townsville Hospital

Where should the money be going?

  • It doesn’t grow on trees

The Australian dollar is limited; nationally we spend $130 billion dollars a year on healthcare, which is 10 per cent of GDP. With substantial cuts announced in the Budget, it’s clear the pot isn’t getting any bigger. So where should we be spending the money? And perhaps more importantly – where are we going to get it from?

One of the biggest challenges is making sure the funds go where they will have the most benefit; it’s not necessarily the specialist treatments and big exciting stuff. There are two sides to this coin. Firstly, who should get treatment and who shouldn’t; secondly, we need to stop focusing on sickness and focus on health.

The table discussion centred primarily on the last 10 per cent of people’s lives and those that lead an unhealthy lifestyle, leaving the two intrinsically linked.

We’re currently spending 90 per cent of funding on that last 10 per cent. We’re also focusing on funding facilities, with not enough action being taken to manage demand.

The simple truth is, the growth rate is unsustainable and people’s lifestyle choices are smashing acute health services.

Some major reform is needed to incentivise people to stay healthy. Our current spend needs to be shifted; all agree that it’s currently imbalanced. Chronic Disease management was also thrown into the mix as a better way to spend money, with more of a focus on long term quality life.

Whether this starts with taxes on unhealthy foods, in a similar manner to cigarettes and alcohol, or wider initiatives around the planning and development stages of community – building in the opportunity for healthy lifestyles.

  • Shifting public perception

The general consensus is that people have the wrong perception of healthcare.

We all enjoy and expect good quality healthcare in Australia, but as we know, it’s not sustainable.

Although the national reform agenda is seeing small amounts of change, it’s nowhere near where we need to be.

One of the potential solutions comes in the form of private health and private insurance. More competition in the area enables it to be available at a reasonable cost. Previously seen as a luxury for the wealthy, few have a realistic concept of the cost.

  • Getting money into the system

As announced in the Budget, the Federal Government could potentially widen the gap to accessible healthcare with confirmation that patients will be charged with a GP tax.

The Government confirmed in its Budget announcement that the much speculated and controversial general practice co-payment model will be implemented.

From July 1, 2015, visits to the doctor will cost everybody $7 with the introduction of a Medicare co-payment. The co-payment will be waived for children and those on concessions only after 10 visits a year. The co-payment will raise $3.4 billion in the first four years, while upfront payments and a tightening of eligibility for the prescription drugs on the Pharmaceutical Benefits Scheme will raise another $1.3 billion.

It’s the continuation of a long debate around co-payment.

Another $1.6 billion will be cut from health by freezing indexation of income thresholds, which determine eligibility for the private health insurance rebate, the Medicare Levy surcharge and other Medicare services.

There are a few problems hindering injections of cash into the health system; inefficiencies from whole-of-regime litigation, excessive tests, limited working hours and supply and demand from private insurers.

The group explored one of the key areas – working hours.

Many facilities are still limited by the 8-5 pool, leaving people with no choice other than to go to hospital. Can we have 24-hour general practices, reducing the demand on hospitals in the same way many health insurers do?

If the health facility functioned on a 7-day-a-week approach with staffing and services, would we be able to provide better care and reap back costs that outweigh operational running fees?

The day public facilities expand the operating hours is the day we can stop building new operating theatres. There’s a trend for more 24/7 facilities – let’s fund the infrastructure but then use it efficiently. A private facility in Brisbane ran its MRI 24/7 – ends up being cheaper to come after-hours.

Public health is getting better with new targets, but it’s some of these efficiency-driving measures that could make the real difference…a little more on that later.

Want to know the other 4? Read the full report here: 5 questions that will make or break Australian Healthcare


Leaders need to step up to drive hospital efficiency

Health is the second largest area of government spend across Australia, and the forecasts aren’t looking great.

National costs are predicted to increase exponentially; at current rates Treasury estimates health expenditure to exceed the entire state and local government tax base by 2043.

It’s pretty clear something has to change; preventative measures are without doubt the best option, reducing the need for healthcare in the first place.

Beyond this, hospitals are the costliest element to Australia’s health system, taking up to 40 per cent of current health expenditure. With that in mind, the spotlight is well and truly on efficiency.

There’s currently a big focus on technology and the potential for increased patient predictions and improved flow. For example, in NSW hospitals have begun publishing real time queue data for emergency departments.

I wanted to explore the driving force behind these changes. As the largest employer in Australia, hospitals have a pretty significant resource at their fingertips that could drive some real change.

With a yearly increase of around 9 per cent in emergency patients, Dr Harvey Lander, Director of Medical Services at Hornsby Ku-ring-gai Health Service is no stranger to finding ways of being more efficient. Ultimately, ensuring people don’t stay in hospital longer than they need to.

Dr Lander has been working on a Clinical Engagement Strategy at Hornsby Hospital that drives mentoring and leadership, and it’s clearly working. He’s been driving a clinical engagement project at the hospital that increased NEAT targets by nearly 20 per cent year on year. He explained the role strong leadership has played:

“Many clinicians have inspired me over the years. Those who thrive on a sense of purpose and mastery of all facets of their profession. The most effective leaders can collaborate, coach, mentor and build superb teams.

“Such clinical champions are needed to affect transformational change. We need to work together to improve our relationships and collaborate to make a difference both for patients and staff.

“There’s a real potential to improve efficiencies throughout the whole process within a hospital. At the core of this change is the ability to get clinicians to the right places at the right time.

“I recently saw a need to improve our care locally, driving a collaborative approach across the whole hospital.”

The project began with a small group of clinicians at Hornsby Ku-ring-gai Health Service, developing a vision of where they wanted to go. The team, with the help of a clinical redesign team leader, developed a one pager to outline what they wanted to do. This was then used to test the project and seek feedback from others that would be involved:

“We shared and market tested with other clinicians whenever we could at clinician meetings and during VMO individual performance reviews. The intent was to make this process about involving our clinicians in a meaningful way, where our most important resource could generate ideas for improving the patient experience, care and outcomes.   We have also been conscious of involving the junior medical workforce, because they are often highlighted as a forgotten group.

“We want to create a positive culture to make things easier and better for our staff, beyond the targets and numbers everyone is used to seeing. We want our clinicians to see, feel and believe that we are supporting the work they do to provide the best patient care,” he said.

For widespread rollout to be effective, it’s safe to say there are a few obstacles. Anyone driving change will know to expect challenges. There are still large pools of people that don’t want to be a mentor. Identifying clinical champions who are willing to get involved and drive change can be challenging. It’s a matter of passion, time, volition and skills.

Dr Lander explained the key to success comes in finding the individuals that are committed, rather than focusing on the ones that aren’t:

“Our clinicians are becoming increasingly committed to driving change that’s going to make a real difference. It’s a tumbleweed effect. Supporting these individuals is vital. We try to acknowledge their ideas and act on them, and celebrate successes to make sure our staff feel valued. This can sometimes be as simple as a genuine ‘thank you’. It also means being approachable and available, recognising the effects system demands on staff, as well as the effects of reform fatigue and burnout.

“Making patients the centre of our collective action has aided us in finding a common purpose and helped inform everything we want to do. We have been encouraging clinical staff to find creative solutions that they can implement. This has encouraged clinical directors to drive a lot of important conversations, helping to set high expectations. We know that competition drives doctors; they want to be the best in their craft and won’t tolerate being left behind. We are fortunate to respect each of our roles – credibility is important. The importance of building, strengthening and even repairing relationships is integral to our improving success.”

Such an impressive increase in results has of course exposed other challenges along the way, including tension between the system and clinicians. But it has also ensured a deeper understanding of the clinician and honesty when looking at individual, collective and cultural differences to help meet expectations (both internally and externally). Dr Lander shared his seven key areas to driving success:

  • Be willing to be involved, and lead if you are so inclined;
  • Be open to inspiration and innovation, share your ideas as they are the most important;
  • Take time to understand your local culture and what drives your clinicians;
  • Be honest about where you are and what needs to be done;
  • Acknowledge any conflict and be ready to have the necessary courageous conversations, but be kind to your colleagues;
  • This is a journey, so have realistic timeframes for the change., It can take five to ten years to change a culture;
  • And look to learn from others in Australia and internationally.

Join Dr Harvey Lander during his presentation ‘Improving Patient Flow with Effective Management and Staff Engagement’ at Hospital Efficiency 2014 in July.

Driving efficiency across healthcare – are nurses the answer?

Australia’s productivity agenda has prompted the healthcare sector to improve efficiency, because patient demand and complex healthcare needs have dramatically increased.

The sector cannot afford cost blowouts, and efficiency is the way forward for patient flow, work flow and waste reduction.

Queensland Health recently set out to achieve an efficiency savings target of $214.8 million to support wage increases outlined within the Nurses and Midwives (Queensland Health) Certified Agreement (EB8) 2012. It has placed the role of nursing in a unique position to champion the productivity drive.

Ahead of Hospital Efficiency 2014, I touched base with Dr Frances Hughes, Chief Nursing and Midwifery Officer for Queensland Health, to get her insights into the challenges, strategies and results of this project.

The role of nursing

Nurses are a major stakeholder in the health sector, with 66,795 nurses and midwives employed throughout the State (as of 30 June 2013).

Queensland Health employs approximately 32,000 nurses, of which the nursing workforce comprises 42 per cent of the entire workforce and 61 per cent of the clinical workforce.

“We are a huge vehicle for change in the health sector, and we’ve had some really exciting efficiency data relating to multiple initiatives. We’re the largest clinical workforce and have a lot of knowledge and depth of capacity to think creatively about new efficiency models,” Frances noted.

Registered nurses equate to 83 per cent of the nursing workforce employed by Queensland Health – approximately 20,823 FTE.

The organisation’s focus on efficiency savings has yielded an incredible $221.3 million return, achieved within 12 months of the EB8 agreement deadline.

“We improved HR management and decreased high cost labour items such as agency, overtime and casual, as well as implemented criteria-led discharge and hospital in the home strategies,” Frances remarked.


A performance scorecard was developed to assist with reporting and monitoring trends across nursing and midwifery services within the public health care sector. These included skill mix, sustainability, productivity and quality.

This scorecard reflects the push to empower the executive directors of nursing with state-wide data to compare. More development is yet to be undertaken towards enhancements in productivity and efficiency measures this year, including a financial impact statement.


Nurses are well placed to collaborate across the healthcare continuum by virtue of their professional knowledge and adaptive capacity.

They are underpinned by numerous options in post-grad professional development pathways – nursing services are evident in all areas of the healthcare system including public, private, not for profit and commercial environments.

Business models

With increased patient demand comes the need to also improve agility within healthcare models.

Queensland Health has delivered nurse-led services through a range of business models including public/private partnerships, Medicare Locals, NGOs and community based services, therefore decreasing demand on acute services.

For example, the Metro South integrated chronic disease clinic, with coordination of heart failure, renal, diabetes and respiratory clinics.

It linked primary and secondary care, resulting in decreased re-admission rates. The savings for heart failure alone were estimated at $885,000 over three years.


Contestability is another element on which efforts have been focused. Frances gave an example:

“We introduced the application of an Investment Management Framework, which demonstrated nurse endoscopy as a suitable patient-focused, cost effective, and quality solution to minimise waitlists and improve health outcomes for Queenslanders. It was supported through purchasing framework levers such as Service Line Agreement targets and incentives,” she said.


Nursing is going through an innovative transformation in Queensland, but there are still lingering outdated policies and guidelines that impact the overall progress of this journey.

There are also outdated models for healthcare delivery, restricted autonomy in clinical decision-making, and a significant amount of supervision that hampers development.

The role of registered nurses needs to be perceived appropriately as well, to enable them to perform the full scope of work.

Frances noted that: “It’s important to support high-performing nursing services through evidence, continued learning, and understand the link between our skill mix, profiles, efficiencies and patient outcomes.”

Chronic health and an aging population are two issues in Queensland from which nurse-led services can manage, given the right framework.

According to Frances, services need to be driven by patient centricity and deliver safe, quality healthcare that is evidence-based.

“Nurses also need to participate in and lead clinical engagement activities and resource management processes. Furthermore, the services should integrate with business models and be a part of the development in health information technology,” she said.

The nursing portfolio is going through innovation for hospital efficiency. Its influence on the direction for productivity gains is already being realised through results such as the $221.3 million saved.

Data and Analytics in healthcare… The revolution is coming.

Technology is sitting right at the heart of the healthcare efficiency drive and it’s easy to see why.

Data-sharing and analytics, collaboration and digital practices will be the driving force behind delivering healthcare services predictively.

Ahead of Australian Healthcare Week 2014, I took a look at some of the biggest emerging areas where technology is driving efficiency to find out what’s on the horizon.

There’s huge potential for information to help bridge the steps towards improving patient safety and quality of care.

To gain an insight on some of the key developments in Big Data and analytics, I caught up with two people on the forefront of driving the change Michael Draheim, Chief Information Officer at Metro Health South and Sarah Dods, Health Services Research Leader at CSIRO.

What are the key areas where data and analytics are impacting efficiency?

Sarah Dods: A lot of what we do in health at the moment is on paper. You can’t do analytics without data and we don’t have big data in health at the moment, in terms of the healthcare system and how it’s delivered, those data fits are only just starting to appear.

We see three efficiency gains that are likely to happen through this process; one is prevention, if you’ve got decision support, crosschecks based on data and information that’s already in the system, there’s the opportunity to prepare and prevent things from happening.

Secondly, using data and analytics operationally, in terms of people,  understanding how the business itself runs and gaining quality assurance,  we see patient flow as being a huge opportunity in that space and one that we’re very interested in.

Finally, digital health delivery, which is another way of talking about telehealth, it’s acknowledging the data that’s collected, telehealth is not videoconferencing. There’s so much possibility because when you do things online, you’re creating data, and you can create data about the information that was shared and use it later on.

Michael Draheim: Service efficiency, service planning, meeting KPIs, predictive analytics and data modelling are a few areas that stand out as opportunities to help us adjust our existing service models to support future health care service delivery.

The richness of the data that we have will help us to understand more about our patients and services which in turn will give clinicians the right information to support the prevention and prediction of disease and treatment options. The impact of this is significant benefits on both social and welfare outcomes along with opportunities for the vendor market to have tools that support this approach.

Where do you see the biggest barriers to growth?

Sarah Dods: A lot of the things that need to be changed to improve efficiency aren’t actually technology related,  but what big data in analytics can do is point you to the problem areas and demonstrate the improvements in flow on to the rest of the system if it was fixed, data is evidence for making change.

There are certainly some funding pressures in  both the primary and the acute healthcare systems, the fact that our primary care system is a straight fee for service regardless of outcome basis, I’m not sure it’s sustainable. But that is a very disruptive change to the way the Australian health system is run, if that ever happens.

Michael Draheim: Historically, we’ve got a whole range of systems that are very disparate, built on data structures that aren’t interoperable and often duplicate the data. It’s difficult to get data out of those old fields as they were mostly free text. You may have a font of knowledge but you can’t extract it without a significant amount of cleansing. We’re now looking at better relational databases and more structure. The big advantage of that is real time categorised information flow. The challenge is dealing with our legacy and the cost of replacing that. There’s also significant organisational change involved.

You also have balance the technology, you don’t want to overwhelm people with thousands of alerts which make their life really difficult. For preventative health, it’s adding those fail safes, but not making too much more work. It’s a fine balance.

Have you any examples of results where you’ve seen technology directly impact healthcare efficiency?

Sarah Dods: One is in terms of cancer reporting where the cancer information that’s currently reported across Australia is a manual process, it’s somewhere between two and five years out of date depending on where you look. When a cancer occurs, a piece of paper gets sent to the cancer authority, there’s about a three year backlog, and somebody then eventually manually enters it into a database. We’ve got some research that we’ve been doing working with a couple of the state cancer agencies about automating that processing of the reporting data, and it’s now getting to the point where the research certainly indicates that there’s potential to do that real-time.

That’s an example where people making policy decisions or looking for unexplained outbreaks of cancer, or carrying out research will have access to be able to make an up-to-date data, it’s a huge advantage. You can then start to look at forecasting.

The second example is around patient flow, we’ve been working with the Gold Coast Hospital for a few years now, and that started out working with their emergency department about predicting who was going to turn up, the question was, can you predict who is going to turn up in an emergency department? We found that using the hospital’s own historic data we can predict with about 90% accuracy in any four hour block who’s going to turn up, what the triage categories are going to be, what the specialist categories are going to be, and how many of those people are going to be admitted.

Michael Draheim: We see significant results where we’ve digitalised existing practices. There’s one example where we’ve saved (from a workforce point of view) about $5 million for a couple of hundred thousand dollar investment – over 18 months, by digitalising a process.

We’ve also put in voice recognition badge software which has allowed clinicians to have more time for patient care – there are direct things that have improved the overall experience.

You can’t measure everything but we’re building a benefit delivery framework into all our projects post go live. We make value estimations and then we measure against that to see how we’re tracking.

What’s next for big data, how do you see healthcare of the future?

Sarah Dods: I’m actually going to be releasing a report on the digital healthcare system of the future at the Healthcare Efficiency Through Technology conference.

I’ve been leading the work that we’re doing at CSIRO around the sustainability of the Australian Healthcare system, it’s about providing evidence for innovation, improving access to services, improving efficiency and improving the quality of care that patients get through using digital tools.

We’re going to be talking about patient flow and information flow and information sharing.

Michael Draheim: It’s about more improving access and the ability to collect, report, read and analyse data on the run. We’ll be taking real time data which will often predict what’s likely to happen and provide this information to clinicians at the point of care to support their decision making. The key is to support the human elements of the way our workforce deliver services with quality real time data –  the challenge in the future is that we’ll have more information, it’s important to make sure this is provided in a way that adds to the quality our services provided by our staff.

Healthcare Efficiency through Technology provides the ideal forum to hear from facilities who have implemented technologies to improve patient care and realise operational benefits. Don’t re-invent the wheel – network, benchmark, learn and succeed.

Healthcare planning for an uncertain future: Adaptability

It’s no secret demands placed on health facilities are constantly changing, which means the services provided need to be flexible.

So can you really plan and forecast the needs of the Australian population?

There are a few strands that emerged during the round table discussion recently held for Australian Healthcare Week 2014 . Stuart Moore (Epworth Healthcare) referred to the analytical information Epworth use during the development stages of projects and how this can help with mapping provisions: “We look at data in terms of trends in clinical areas of all sides, public and private, across Australia. We use this data to try to map out growth areas across Victoria (the market in which we operate). That information directly impacts the development projects for our existing sites. We also look at Greenfield opportunity sites in Geelong.

“That information is used alongside the figures we get from Government forecasting such as funding models etc.”

There’s a whole range of information available from the Government that can be incorporated into plans. Anna Morgan (Southern Health) uses information based on areas of growth to gain a better understanding of the timing for expected growth in particular areas when mapping out services.

“The growth catchment predictions impact decisions made in our area quite heavily. We have a lot of older established areas that we currently serve, but in the outer regions there are identified nominated growth areas. We have to understand what the time frames are for that growth so we can incorporate them into our plans.”

The fluctuating population growth rates and behaviour predictions of those people have certainly been a challenge for health facilities in the past.

Leonie Hobbs (Carramar Consulting) has first-hand experience in Queensland, where unexpected population growth led to a long term design predicament: “We closed many beds because we had huge facilities at the time. Then something happened that we weren’t expecting: we had a huge population influx. We hadn’t designed to manage that. That’s the dilemma we are still stuck with now. The population modelling was done correctly, it was the provision of services themselves that we got wrong – we were hearing people would use more ambulatory services and therefore need less bed days, but we still needed the beds.”

So how can we really predict population? Ultimately, modelling can never be exact, but the message is to use the data sources available to make the most informed decisions.

The workforce challenge

Of course, the adaptability challenge extends beyond the build of facilities to occupy surrounding communities; the service itself needs to be just as flexible.

Two themes tie into the debate: the provision of services themselves and the location.

Perhaps one of the most interesting pieces of research happening currently is in Queensland around contestability. Leonie explained: “With the potential of outsourcing public work, there’s becoming a trend in QLD, NSW and WA where we are seeing more of a ‘Fee for Service’ model provided by the private sector. This may be something on the landscape for the future.”

Time will tell how much of an impact outsourcing and contestability will have. Projections produced by HWA in the ’Health Workforce 2025’ report make it pretty clear that without major reform in the pattern of health service delivery, Australia faces huge shortfalls in the nursing and related workforce nationwide, and in the supply of general practice and many specialities outside inner metropolitan areas.

There are considerations that should be made during the design and development to start to tackle this challenge.

The first is around staff and the experience they have. If we make our facilities a better place to be, we’re more likely to retain staff. The roundtable participants discussed how the biggest asset to any facility is the people who work within it, they therefore need to also be at the centre of the design.

We looked at several examples, ranging from the layout of facilities to providing open spaces for staff to relax and research.

The second consideration is around how we’re providing the service itself and a question that was raised by Arch Fotheringham (Brookfield Multiplex): “Are we taking the person to the facility or the facility to the person?”

Location based health

As mentioned earlier, the Government growth reports are one tool for forecasting. Arch suggests that it’s important not to reduce options when providing services in these expanding areas: “It’s easy to say there’s a growth area but you need to look at how you get people out to where that facility is. A good example is if you look at the Western Melbourne area, where a large percentage travel to Central Melbourne for treatment because it’s not available in that area. It extends beyond buildings…”

Anna spoke of a recent project in Dandenong, where they experienced similar location issues. The team are in the process of building new and improved facilities at Dandenong Hospital to ensure continued access to the highest quality of care for the community.

The work redevelops a number of community and ambulatory care services provided in disparate locations, bringing them into one central precinct. It’s an approach that extends existing services rather than builds new ones.

“As we continue forward, we’re about to do master planning in a growth area to do a very similar thing to what we’ve done in Dandenong. It’s about community services, medical consulting, allied health consulting and referring back to our main bases in adjacent areas where the tertiary services are. Understand the services you already have, look at how you can build on them.”

We couldn’t look at location services without discussing at least part of the rural health challenge. We have an ageing population; a large number of people are retiring and moving out to more rural areas where there aren’t as many accessible sub-acute services. They currently have to gravitate back into the capitals.

The population will still also continue to be dispersed – inner city health facilities are run off their feet whilst rural facilities are much quieter and come with their own workforce challenges.

Australia can’t continue to be so metro-centric.

Leonie confirmed, “The models of care are changing rapidly. We design to a model of care and it quickly changes. Take cancer care: we used to bring patients in for treatment and get great outcomes and survival rates. We’re now seeing the day ambulatory oncology unit gets just as good outcomes. Another example is around physiotherapists. I’m consulting with a facility at the moment that has a strong Allied Health background, the whole structure needs to change as we’re now moving into therapy aids. There will be fewer physios and more aids, more groups and less individual spaces. I’m learning people will require less cube rooms and bigger group spaces. We have to be flexible enough to change models of care.”

Solutions need to be found and they’re expected to be driven through design innovations, extended workforce training and technology.

Next week we’ll cover ‘Part Two:  Funding’ or download the full report here: