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

5Q

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.

[Exclusive interview] Building powerful partnerships at Queensland’s new Lady Cilento Children’s Hospital

The new 359-bed hospital will be the biggest public children’s hospital in Australia, and the central hub of an enhanced state-wide network of children’s health services.

The Lady Cilento Children’s Hospital merges staff and expertise of the Royal Children’s Hospital and the Mater Children’s Hospital

It is part of a $1.5 billion program of work, including an adjacent academic and research facility, the refurbished headquarters of the Children’s Hospital Foundation; land to accommodate families within the precinct; improved road access and a new Adolescent Drug and Alcohol Withdrawal Service building.

Developing Queensland Children’s Hospital has been no easy feat. The overarching challenge: bring together two old (but long-standing) children’s hospitals and win people’s hearts…

Ahead of their presentation at Australian Healthcare Week 2014 in March, I caught up with some of the people tasked with steering the project from concept to completion: Dr Peter Steer, Chief Executive, Children’s Hospital and Health Services, Bruce Wolfe, Project Director at the project’s architect, Conrad Gargett Lyons, and Tim Treby, Project Director for the managing contractor, Lend Lease.

Could you outline your involvement in the Lady Cilento Children’s Hospital and where your focus lies?

Peter Steer: I’m the Chief Executive of the Children’s Health Queensland Hospital and Health Service that will be running and managing the facility at the end of the day. I’ve been involved for five years now, and my focus is to ensure that we deliver a contemporary design that delivers against our vision and mission, which is a really patient- and family-focused healthcare service.

Bruce Wolfe: This was something of the ultimate architectural prize so, initially, my involvement was bidding on the project; then Master Planning and developing the building concept with the design team, health planners and client. In many ways my role involved managing the complex relationships on the project and that is my focus now as the building nears completion

Tim Treby: I have been involved in project for over 6 years, from commencement of the Master Planning phase as Building Consultant initially, and then as Managing Contractors representative.  I am responsible for delivering the building to meet the expectations of the client and the many other project stakeholders.

The success of the project relies heavily on effective collaboration and communication. What would you say is key to getting this right?

Peter Steer: The relationship between the principals on the project. We were very fortunate with the appointed architectural team and the managing contractor as those relationships are critical. The other critical communication issue in health is the quality of stakeholder engagement and, in particular, user group engagement.

We learned through the project that you can’t over-communicate in the context of these complex designs. The healthcare professionals using the facility feel very strongly about their services.   There’s a significant education element around that stakeholder and user group engagement. It was one of the things we got better at as the project progressed.

I’ve been involved in a number of significant projects before and am continually surprised at how difficult it is to bring people along. Some clinicians have strong opinions and their expectations are very high, and not always contextually appropriate for the capital build. There are real challenges in managing stakeholder user groups. We took the communication and listening process very seriously. We went back repeatedly to review and subsequently did some significant schematic re-design work because we were keen to ensure people felt listened to.

Bruce Wolfe: Time spent listening is always valuable; listening to both ideas and criticisms. It’s crucial to moving forward collectively.

Tim Treby: I agree that the success of any project relies heavily on effective collaboration and communication.  The larger and more complex the project, the more challenging this becomes, and the more important it is.  This project has been extremely challenging in virtually all aspects of the development process, and the toughest issues to overcome, in hindsight, have been those where communication and collaboration have been lacking in some form.  We are fortunate to have a client who recognises the importance of this and we are able to communicate openly and resolve potential issues early. 

What preconceptions did you bring to the project and were they reinforced or altered?

Peter Steer: My preconception was that it was going to be a very complex capital build and that there would be issues around our workforce merger, given that this was bringing two hospitals together.  They’ve been reinforced – it’s a very complex project that is now going well, I’m not sure there’s been anything like it in this country before.

Bruce Wolfe: At the interview for the project, we talked about a very different type of hospital, open and “permeable”. I actually wondered whether this may have been too big a move for Queensland Health but it the opposite was true, the client was keen to embrace innovation and bring new ideas to the planning including the concept of a more open and community connected hospital. The site was also challenging and involved a broad review and evaluation of the urban context. This was fundamental to the success of the project and in reality was every bit as complex as imagined.

Tim Treby: This was always going to be a technically challenging project; a heavily serviced hospital including an energy facility on brownfield site bounded by major arterial roads, bus tunnel, schools, hospitals, residences and a telephone exchange. Having been involved in many hospital developments before the LCCH this was understood, and has been reinforced many times over during the life of the project.   The project has traversed several cycles, including economic, political, industrial, corporate and stakeholders which have all had to be negotiated.  I knew that the project team would have to be tenacious to overcome the challenges that would and have come, and also that we would be all be justifiably proud of the end product.  It is a fantastic result.

QCH was not a public-private partnership. Do you see any benefit of using this new PPP style?

Peter Steer: We benefited from not being a PPP, primarily because the site was complex and had some major design challenges, along with the organisational merger; engagement was critical. And certainly the procurement process and the choice of managing contractor versus a PPP allows a lot more user and stakeholder engagement. That was the advantage for us.

In terms of Public-Private Partnership, given the challenges for government finding injections of capital money, PPPs will become more attractive. PPPs will be a mechanism (and not an unreasonable one) to deliver these big projects that otherwise will simply not get off the ground. PPPs certainly have their place and their advantages, but I don’t think there’s a perfect methodology. The mechanism of procurement really does need to fit the purpose and context.

Bruce Wolfe:  Shortly after the design of QCH, CGR won the commission to master plan and provide the design of the Reference Project of the Sunshine Coast University Hospital, a PPP project on a large scale. One of the difficulties in the PPP process is getting sufficient client and user-group contact with the competing design teams. I think that was well handled in that project but it remains a difficult aspect of PPPs. The benefits are in relation to the capital cost savings for government and allowing the health experts concentrate on delivering their core expertise.

Tim Treby: They appear to be desirable from a public funding point of view, however I think that the cost to industry to bid for PPP tenders is excessive and unsustainable.  There must be a more equitable procurement methodology that can be developed.  I would question whether they are sufficiently client focussed for particularly complex projects.

How is the project responding to a change in customer demands?

Peter Steer: Things have changed enormously over the last seven years.  To be both accurate and give praise where it’s due, the architects in their design have designed a facility that maximises flexibility.

As our understanding of service models has matured, we have had to make changes. We’ve obviously had to draw a line in the sand, but we were fortunate with a flexible design in the first place that has allowed us to survive well with adaptation over that long period of time between design and delivery.

Bruce Wolfe:  Our customer for QCH was Queensland Health. In the long delivery of such a project there are inevitably changes in their demands that impact on planning. The versatility and flexibility of the design was tested during that six year period from master planning to completion.

Tim Treby:  I think that when the Hospital opens people will be impressed with this building.  It is a facility that has the welfare of its young patients and their families firmly in mind, as well as the needs of staff and visitors.  There has been future flexibility built in, and much work done by the client, design and contractors teams to ensure the latest technology is provided in the facility, considering the lead times which have had to be managed.

What have been some of the biggest challenges you faced throughout the development of the project? Are there any lessons learnt?

Peter Steer: It’s critical in any healthcare design, particularly given the context of our merger and bringing two organisations into one, to get that engagement right. The other opportunity is getting stakeholders to understand there may be design solutions and technology solutions to some of our service delivery challenges at the moment.

A classic example of such an opportunity was in our outpatient design – we had our clinicians absolutely horrified that there was very little waiting space within this hospital for clinics etc. When you think about it, at first, a patient might think, why don’t we have larger waiting areas? But, the principle about being patient- and family-centric with this children’s health service is not to have people wait, and to design a facility that would enable waiting makes no sense.

You can create tension by your design, your intent and your vision for the organisation, and through technology, make a real difference to a design solution. There’s a major change agenda, a service change opportunity, with these big design projects, it’s difficult to grab them.

The other challenge is that on a really big, long project, the team changes. You have changes in personnel, particularly in the public sector, in the bureaucracy with whom you’re interfacing, and often have government changes. Managing that change can be a challenge.

Bruce Wolfe:  This was a complex and testing project and there were really no areas that were not a challenge.  A difficult brown-field site, two separate and very different organisations coming together, a highly visible project politically and a turnover of client project directors during the course of the project. The challenge was to stay focussed on the architecture and the building and the problems that were in a domain where we could be most effective.

Tim Treby:  As I have already mentioned there has been no shortage of challenges on the project.  The site location provided many technical and logistic challenges, and the form of the building required a lot of planning to develop methodologies to safely construct it, and it did drive innovation.

The clarity and alignment of expectations for the user group approval of the developed design was challenging, and exacerbated by external criticism and lack of continuity of some participants.   The importance of external stakeholder engagement was recognised and managed well.

There has already been a lot of interest in this project from a design perspective. What has been your impression from that commentary?

Peter Steer: This project (and certainly the design that’s put on the table) is centred on creating a green and healing environment.

This vision has permeated everything with extraordinary attention in design, designing to minimise use of electricity, having our atria and major thoroughfares in the hospital, open to the environment.

There’s also a community vision where the intent of the architects has lived true, they’ve ensured the hospital is open to the community. There are major ‘windows’ that allow people both to see in and see out from this facility, which not only helps with finding context about time of day and place, space and time, but also builds community connections. For a children’s hospital, this is critical.

Bruce Wolfe:  The building occupies the site quite powerfully which has generated discussion both for and against. As the building is revealed, the gestures of opening the building façade and connecting the inside spaces to the outside is more apparent and helps in the scale of what is a very large building. There is more of the ground plane also given to the public.

We have been pleased with the comments as the scaffolding has come down and surrounding buildings removed to reveal the civic domain.

It was also pleasing to be the first Australian hospital to win the Academy of Design and Health Award for Best Future Hospital

Once it’s open and people get to experience it, as opposed to looking at pictures, I am sure the impact will be much, much more significant.

Tim Treby: The external appearance tends to be polarising, and it certainly has people talking.  The finished product being delivered is true to the brief and design intent, and will provide fantastic facilities.

The project has clearly seen lots of innovation. Have you any examples of how it’s acted as a catalyst for change for other hospitals?

Peter Steer: There’s little doubt that our emphasis on service planning and patient flow as a result of this process is influencing ambulatory care delivery across Queensland. We’ve been innovative in terms of our ambulatory clinic not just design, but service. We’ve got some great feedback and interest from health services across the State. It’s that interface between service design informing building design that has been the advantage.

Bruce Wolfe: I think it is probably too soon to tell but I think that since the design of this building was revealed in early 2008, there is a renewed emphasis in hospitals on intuitive way finding and creating public spaces in the building that link to form a network of volumes rather than of corridors and passageways. There have been planning innovations as well but these would be tested in practice before being adopted more broadly.

Tim Treby: The have been many innovations implemented during the construction phase, which will no doubt be used on future projects.

Hear more from Peter Steer, Bruce Wolfe and Tim Treby during their exclusive presentation at Australian Healthcare Week:  ‘Queensland Children’s Hospital: The New Look PPP’s: Powerful Precinct Partnerships’ This project case will focus on the new Children’s Hospital Project, demonstrating a strong collaborative process adopted by the client, architect and contractor which has ultimately acted as a catalyst for change