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Public Sector Cost Saving Initiatives of 8

Australian Nursing & Midwifery Federation (Tasmanian Branch)

Tasmanian Budget Implications

Tasmanian Public Sector

Cost Saving Initiatives

ANMF Submission

June 2014


Australian Nursing & Midwifery Federation (ANMF)

Organisation Overview

The Australian Nursing and Midwifery Federation (ANMF) is both the largest nursing and midwifery union and the largest professional body for the nursing and midwifery teams in Tasmania. We operate as the State Branch of the federally registered Australian Nursing and Midwifery Federation. The Tasmanian Branch represents over 7,200 members and in total the ANMF across Australia represents over 240,000 nurses, midwives and care staff. ANMF members are employed in a wide range of workplaces (private and public, urban and remote) such as health and community services, aged care facilities, universities, the armed forces, statutory authorities, local government, offshore territories and more.

The core business of the ANMF is the industrial and professional representation of nurses, midwives and the broader nursing team, through the activities of a national office and branches in every state and territory. The role of the ANMF is to provide a high standard of leadership, industrial, educational and professional representation and service to members. This includes concentrating on topics such as education, policy and practice, industrial issues such as wages and professional matters and broader issues which affect health such as policy, funding and care delivery. ANMF also actively advocates for the community where decisions and policy is perceived to be detrimental to good, safe patient care.

Contact Information

Neroli Ellis, Branch Secretary

Australian Nursing & Midwifery Federation (ANMF) Tasmanian Branch

182 Macquarie Street, Hobart TAS 7000

Ph: (03) 6223 6777

Fax: (03) 6224 0229

Email: [email protected]

Website: www.anmftas.org.au

mailto:[email protected]

http://www.anmftas.org/


Introduction

ANMF (Tas Branch) provides this follow up to the previous ANMF Tasmanian Public Sector Cost Saving Initiatives submissions of 2011, 2012 and 2013. ANMF has consulted with public sector members and many of their efficiency solutions have been previously raised, however, not implemented. The systems are inefficient and do not support health delivery, rather at times obstruct efficiency.

1. Strategic issues

1.1 Review the current governance and structure of DHHS and three THO’s. ANMF supports a review and potential amalgamation of THO’s conditional on regional clinical and consumer representation.

1.2 Implement a state-wide strategic health plan and policy consistency.

1.3 Ensure clear lines of delegation and accountability.

1.4 Review under utilised rural hospitals to ensure admission for acute care is streamlined to optimize utilisation with universal admission criteria.

1.5 Clarity is required on which services are recurrently funded and which services are not funded.

1.6 Conduct a feasibility study on elective surgery privatisation.

1.7 Review the Private Patient Trust Scheme for private patient revenue to consider redirection of those funds into the general recurrent funding pool and ensure equitable public access.

1.8 Review and re-allocate the remaining Tasmanian Health Assistance Package funding to best meet Tasmania’s needs and ensure actual sustainable implementation rather than funds being depleted on consulting and disparate projects.

2. Management and Human Resources (HR)

Timely resource management will increase efficiency and reduce costs. There remain frustrations for Nurse Unit Managers (NUM) managing budgets without input, timely release of the budget in the financial year and lack of flexibility to achieve savings. Double shifts worked in each region per month are as follows: THO N 139 (April), THO-S 118 (May) THO-NW 74 (April) 1

2.1 Nurse Unit Manager budget control

2.1.1 Give Nurse Unit Managers budgetary control with Business Manager support and remove prescriptive establishments: i.e. allow managers to staff to a skill mix FTE made up as they deem clinically appropriate.

1 figures are from most recent month available


2.1.2 Ensure timely delivery of budgets to ensure the flow on budget money is

available 1 July.

2.1.3 Enable capped purchasing (to a preset limit) to utilise sales and opportunities.

2.1.4 Some Nurse Unit Managers have no financial delegation to authorise purchases to any dollar value, (RHH NUMs have zero budget allocation) therefore needing higher authorisation to purchase basic equipment e.g. sanitary pads. Delegate NUM authorisation to a minimum of $5000 as is current practice at THO-N.

2.1.5 Challenge each manager to continue to identify savings in each unit. Ensure all savings are maintained in Unit. Enable and support NUM’s to implement change.

2.2 Human Resource Management;

The current system requires 9 levels of sign off to commence the recruitment process for a funded base grade position, resulting in delays and subsequent roster shortages. These roster shortages often require overtime and double shifts to meet staffing requirements.

2.2.1 Fill vacant positions with permanent staff, which is a cheaper option than

using casuals and/or paying for double time/overtime and agency staff. 2.2.2 Ensure timely recruitment with clear KPI’s for each stepped process to

ensure accountability with aim of maximum recruitment period of six weeks, not current three months.

2.2.3 Streamline rostering and Human Resources (HR) processes e.g. employ

specialist field HR groups employed by the DHHS for HR duties rather than Nurse Unit Managers conducting full recruitment process for all applicants, including all administrative paperwork.

2.2.4 HR Data - data not received for cost centre on cost of FTE employed

due to page up system. 2.2.5 Enable recruitment of budgeted base grade positions to be streamlined

without requirement for multiple signatures to approve. 2.2.6 Doctors can presently be employed as a full-time medical officer and

have their own private practice. There should be some limitation around this and all day hours should be worked in public.

2.2.7 Nurse Graduate recruitment inefficiency as three separate application

processes and no co-ordination of offers so a graduate nurse may receive three offers with associated inefficiencies and additional stress on graduates missing out on Round One offers.

2.2.8 Equity in employment of Agency staff - Medical locums are paid over

$3000 per day whilst a policy banning agency nurses remains in some


sites, resulting in double shifts due to shortages. Limit agency locums and provide transparency when utilising this employment system e.g. Locum New Zealand Orthopedic surgeon employed at RHH over Easter to cover annual leave of all permanent orthopedic surgeons. Manage annual leave/professional leave to ensure ongoing coverage from employed staff.

2.2.9 Project/policy positions must be audited and a report tabled to be

discussed with ANMF to identify any potential reduction. 2.2.10 Pay office remains an obstacle and their unilateral interpretation causes

inefficiencies and waste of their resources in managing disputes for Managers.

2.2.11 Senior Executive & SES - Includes Bands 9 & 10:

No increase in numbers in any agency

Assessment of all entry level SES positions to be reviewed on vacancy to establish whether position is required

Targeted reduction of SES offices in areas where there are disproportionate numbers

3. Systems

The current systems are inefficient and add to the frustration and waste of resources. An upfront budget allocation needs to be considered to save in the longer term. Discharge processes: 3.1 Implement criteria led discharge (led by a Registered Nurse). Registered

Midwives currently have ability to discharge and this has proven efficiencies. 3.2 Review the current practice where patients have the right not to be discharged to

certain nursing homes whilst preferring to remain in acute bed. 3.3 Medical Grand Rounds should be directed to be in a.m. to enable early

discharge and Interns should have reviewed results and discharge scripts prior to rounds. This will improve communication in regard to patient requirements (including required diagnostics), expected date of discharge etc. thus improving efficiency and ensuring timely discharge. There are still cases where patients remain in acute beds when alternative discharge could have happened.

3.4 Weekend rounds should be prior to 1100 as pharmacy closes at 1400 hours

Pharmacy closes at 12 on Saturdays at LGH and is not open at all on Sundays. 3.5 Pharmacy meetings should be rescheduled to end of the day rather than 0930,

which delays scripts etc. as the meeting is in progress in a.m. Iron Infusions should be available in a.m. not 1400 therefore elimination of overnight stay.

3.6 All patients admitted to Hospital should have a planned date for discharge. This

could be publicised on a whiteboard and colour coded to ensure high visibility for


planning. This may prevent nurses constantly following up and inefficiencies in the discharge system.

3.7 If hospital pharmacy, allied health and radiography provided 24 hour coverage or

had an improved on-call service this would prevent unnecessary admissions or reduce length of stay. Alternatively there should be a cost analysis between the expense of providing additional cover in these services compared to increased length of patient stay/increased admissions.

3.8 After hours and on public holidays, social workers should be available on call. Stock control: 3.9 There are no auditing processes at present to monitor non-stock ordering, which

results in significant waste. Statewide ordering is still not happening, e.g. pens.

3.10 Community teams - delivery is currently charged by RHH, which is sometimes more than the price of the equipment. Enable Community managers to order direct without need for RHH courier.

Current IT system 3.11 Out of date and causing significant inefficiencies. New integrated system is

required. Current systems do not interface e.g. PAIS (Patient Admission Identification system) with pathology system, pathology system does not interface with radiography. Empower system is the payroll system which does not interface with rostering system ProAct. For example. the PAIS system uses the statewide patient ID but pathology system (LGH) can only use the old patient ID numbers.

3.12 Integrate retrospective pays and rostering into ProAct. Clinical redesign 3.13 Implement lean systems: The key areas of wastage in hospitals are waiting (for

beds, for test results); queues (patients queuing for a test); errors (wrong procedure, medication errors); transportation (moving patients, moving equipment); motion (staff searching for equipment, paperwork, outlying patients); over-processing (unnecessary tests, duplication); overproductions (referrals made too early). Implement processes to minimise this and this will not only increase patient flow, but reduce budgetary waste. Flinders Hospital in South Australia has a good model and has implemented this effectively. Victoria DHS has also implemented an excellent framework. Fund project positions to ensure savings. Improve IT systems to enable collation of financial data to facilitate measurement and evaluation of savings.

3.14 Implement a Nursing Clinical Information System to ensure streamlining of

processes, prompt action of variation and length of stay and implement research/evidence based improvements in systems and delivery of care. Introduce electronic progress notes rather the hard copy and scanning.

3.15 Review in-patient length of stay and provide analysis on why it is longer than the

mainland and what options are there for outsourcing, particularly with patients who are homeless, have a disability or mental health issues.


3.16 High risk mental health patients to be transferred to Wilfred Lopez Centre and public education to be provided to diffuse the stigma attached to this facility due to its location and forensic health status.

3.17 Clinical Re-design of Outpatient Departments to improve access, efficiency and

sustainability to reduce the number of no-shows. 3.18 Review respite/sub acute facilities access in mental health. 3.19 Medical Staff undertaking surgery on private patients in the public system

(because of the unavailability of specialist equipment in the private sector) should be obliged to ensure early transfer of the patient back to the private sector once the patient conditions so permits.

4. Clinical Diagnostics and Disposables

4.1 Each patient should be benchmarked to determine expected costs in regard to length of stay (cost of each bed day), diagnostic tests, disposables etc. dependent on admission. There is currently a policy of risk aversion and ordering all diagnostics rather than limiting to specific testing. Benchmark diagnostic ordering per Medical Officer.

4.2 Activity Based Funding will require transparency, education and benchmarking. 4.3 Publicise the outcomes of each provider and ensure transparency. It would be

possible to have ‘levels of tests’ that can be ordered by various medical practitioners, e.g. Interns might be limited to ‘routine’ tests only, Registrars to a ‘higher level’ etc. This has been implemented NWRH DEM.

4.4 Standardise prosthesis – remove surgeon’s choice. So much stock is ordered

based on Doctors ‘needs’ or preferences. For example they will only use one brand of joint for joint replacement surgery. If each surgeon at each hospital only uses one preferred brand, each hospital has very expensive joint trays that often expire prior to their use.

4.5 All stock items should be labeled by non nursing staff with their price per unit in

the store rooms. If staff are made aware of unit pricing they will be more conscious about the use of these items whilst still providing optimum care to the patient.

4.6 Equity of access to quality equipment as it has been reported that private

patients in public hospitals receive different quality equipment e.g. stents than public patients.

4.7 Use local hotels rather than acute beds for pre and post acute care. The

Fountain Hotel is now being utilised in the South but without access to nursing staff and there is no option in the North or North West.

4.8 Outreach services could be broadened to reduce inpatient days. Issues with

transport and bed access remain with an inability to transfer patients back to their


home region causing delays. Independent patients requiring minimal daily clinical intervention in hotel beds will reduce the cost of additional inpatient days.

4.9 Re-introduce Hospital in the Home in the North to minimise patients waiting to

access limited services but remaining as inpatients in acute beds.

5. Transport and Travel Expenses

5.1 Book accommodation on discount websites such as “Wotif” or “Last Minute”. Individual hotels often have reduced rates when booking directly with them, but closer to the date. Slow processing of request forms results in late bookings and more expensive costs.

5.2 Car pooling should be promoted. It is not unusual to see several DHHS cars with

only one person despite the fact that several people are going to the same meeting from different regions.

5.3 Transport of patients on return to their home, who may be incapacitated, would

be better supported by an internal transport system rather than the use of public transport.

6. Executive, Government and General Administration

6.1 Monitor and reduce the amount of paper used throughout the public sector. Print on both sides of the page and proof read memorandums requiring printing to condense to one page.

6.2 Charge full price for meals for non staff at cafeterias in all hospitals. 6.3 Introduce motion activated lights in all corridors and non-essential areas (e.g.

lecture theatres, toilets, cafeteria areas etc.).

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