Collaboration, Culture and Outcome

11 am- 11: 40 Tuesday 13th November

Todd McEwan

Director Operations Acute Hospital Network

Hunter New Englad Local Health District

Metaphor for Waiting List Management

It’s managements problem!

• Waiting lists are an artificial political construct

• I won’t recategorise

• Just give me more time

• You don’t listen too me I know whats right for

my patients

• It’s your problem because you wont resource

us to the level the community expects

Managements issues

• Medical autonomy is Dead

• There is significant variation in what you and

your colleagues do in managing your waiting

list

• I agree waiting lists are an artificaial political

construct, but surely getting the patient done

on time is in the patients interest

• Don’t use the patient as a pawn

• Excellence Every Patient Every Time

Gynaecology Services around Newcastle

• JHH/ RNC: – 12 OT theatres

– 1208 elective gynae cases

– 439 emergency gynae cases

– 1057 Obstetric Cases

– AAAA Clinic Attendances

• Belmont Hospital – 4 OT theatres

– 600 elective gynae cases

– 13 emergency gynae cases

• Maitland Hospital – 4 OT theatres

– 497 elective gynae cases

– 144 emergency gynae cases

– 684 Obstetric cases

• Peripheral primary and community hospitals – Singleton, Cessnock etc

– 220 elective gynae cases

Strategy

Challenges faced

• Medical staff had fractional appointments

• Consequently their work schedule was inflexible Additional OT sessions and leave relief were difficult to schedule.

• Imbalance between surgeons with OT capacity and surgeons with waiting list challenges

• Although the majority of surgeons were agreeable to the idea of pooling patients it did not work in practice as the bureaucratic and practical barriers were insurmountable.

• Wide division between gynaecology and gynaecology oncology service

• Relationship between the neighbouring facilities

Risk Management

Collaboration

• There were significant internal issues not

readily apparent

• The tangible a intangible issues had to be

dealt with

Clinical and management changes implemented

• Clinical Leadership Model

• Change in surgeon staff profile

• Enhanced flexibility

• Close relationships with “satellite” facilities

• Additional OT time

• Administrative and booking staff support

Additional OT time

• 20% increase in OT time since 2009

• Although the Department could not initially see

how the additional OT time could be

accommodated, it was initially absorbed by

utilising VMOs who primarily worked in Obstetrics

but were willing to accept elective patients from

other AMO’s gynae lists.

• As time has gone on and a number of specialists

went part time and more specialists were

employed the new surgeons accepted these lists

Additional OT time

We have done approximately 40 hours of surgery a month more

(approximately 10 sessions a month across BDH and JHH)

Not surprisingly, providing OT access alone was

not the solution

Discussion of the non-tangable and

cultural aspects

All washed up!

Culture

• Leadership drives change

• Accountability delivers outcomes

The Clinical Leadership Model

• Rather than just one Clinical Director and a

Service Manager there is now a leadership team

representing facility management, foetal

medicine, gynaecology, obstetrics, gynaecology

oncology, registrar training supervisor

• Focused Accountability

Common Messages

• Key messages from the leadership team are

– Enthusiasm for working in the public sector

– Acceptance that there will always be differences

between the public and private sector

– A commitment to finding professional satisfaction

not just hip pocket satisfaction.

Change in staff profile

• Staff specialist v VMO: it is not employment

model but the cultural model that is important.

• Introduction of Post Graduate Fellow: resulted

in significant service provision improvements.

Also able to provide training opportunities

• Enthusiasm for the public sector.

Administrative and booking staff support

• Waiting List Manager

• Manager of Outpatient Clinics

• Admissions staff

• Theatre Manager

• Administration and administrative staff within

the department.

Flexibility

• Incorporate increased flexibility into work

patterns

– Surgeons

– Clinics

– Administrative and waiting list staff

– Patients

• This has also required a realistic assessment of

medico legal risk over such things as

transferring care between clinicians.

Movement between sites

Close relationship between facilities and surgeons allowed patients

to be operated on at the clinically appropriate site which allowed

the most rapid admission

So it’s a game of Chess?

What do the changes feel like on the ground?

• Admission staff no longer fear the routine

auditing of the gynae list as now when there are

enquiries about waiting time, positive

expectations and viable alternatives can be

expressed.

• There is a reported reduction in the number of

patients ringing with enquiries (and greater

reduction in disgruntled enquiries)

• It can look like a headache for the waiting list,

admissions, clinic and operating theatre staff

What do the changes feel like on the ground

• The Surgeon’s perspective

– “Feels like admissions aren’t always on your

back about lists”

– I’m not in McEwan’s Office every week, that’s

better for me and him!

What have we achieved across BDH and JHH.

• July 2009: 732 pts. On

list an average of 142

days,

• Jan 2011, 760 pts. On

list an average of 192

days.

• Sept 2012 702 pts On

list an average of 113

days.

The referrals did not stop

And our number of additions and removals remained reasonably

aligned.

Composition of the Waiting List

During this time, the relative contributions from each urgency

category remained essentially unchanged

Common Goals / Accountability

• Manage the change over of post graduate fellow

• Some surgeons with specific demand problems

exist, but these are increasingly seen as a

departmental problem requiring whole of

department solutions

• Potential introduction of a mechanism of

creating a “free agent” surgeon.

Challenges ahead still?