BEYOND2020: Reflections from the early years
13 November 2020
The Health Roundtable has a unique and privileged place in the Australian and New Zealand health care systems. However, the early years of the organisation required a combination of foresight, determination, right place at the right time, collaboration, expertise and pure effort.
We interviewed a number of former Board members and supporters on their reflections on the organisation. Combined they have over 40 years participation and volunteer service to the Health Roundtable. They include:
- Colin Macarthur (Liverpool), 1996-2000. President 1996-7, Treasurer 1998-2000
- John Menzies (Royal Brisbane), 1997 – 2002. Treasurer 2000-02. John also served as General Manager 2014-2018
- Jennifer Williams (Austin and Bayside), 1999 – 2009. President 2003-04, Vice President 2000-02.
- John O’Donnell (Mater, Qld), 2004 – 2014. President 2008-09
- John Youngman (Princess Alexandra), an early supporter and advocate for the inaugural meeting in 1995
- Michael Walsh (Bayside and Cabrini), 1997 – 2002, 2017-2019. President 1999-2002.
Below, in no particular order, are their reflections on the early years of the Health Roundtable.
What was the background to the HRT’s establishment? What were the issues that were being explored?
The two key drivers of the initial concept were Mr Bill Kricker, who was the CEO at the Alfred Hospital, and Mr David Dean who had a passion for analysing hospital data and turning it into useful clinical and business information for hospitals. Dr John Youngman, who was at the time the CEO at the Princess Alexander Hospital, further championed the concept in early 1995 (which he continued as the newly appointed Deputy Director-General in 1996).
Late in 1995, there was an evolving change [in some states] from Regional Health Authorities to District Health Services, each with their own new Board of Management. Queensland’s two largest hospitals i.e. RBH and PAH both had an interest in evolving to better administrative structures and service improvement that relied more on modern management activities including benchmarking of clinical and general performance. Dr John Menzies was appointed as the first CEO of the Royal Brisbane and Women’s Hospital DHS and Mr Lindsay Pyne for the Princess Alexandra Hospital. They were the first two Queensland Directors of the original first full 11 member HRT Board of Directors along with the nine others from New Zealand, Victoria, NSW, South Australia and Western Australia.
In the mid-1990s there was concern that certain jurisdiction’s Health Departments could demand that participating hospitals provide their benchmarking information and the data of other Australian Hospitals. Accordingly, a decision was made to use code names for hospitals. The Code of Conduct was also developed that ensured that no member used the data to criticise the performance of any other. In reflection, this may not have been needed as the data over 25 years has shown that there is no perfect hospital that is an exemplar in every category of service that they offer. Every facility still has a number of areas where improvement can occur.
The founding 11 member Directors of the initial Board of HRT oversaw the growth of HRT activities for its 11 members. By 1997-98, the value of the HRT became more widely known and the Board recommended the establishment of the All Stars Chapter which allowed another 11 major Australian and New Zealand hospitals the opportunity to participate.
The key background was the decision by David Dean to take a different model and to produce a more collegial approach. I think our hospital was invited largely because of the interest at the time in Day of Surgery Admission of elective patients, which had been developed here.
I didn’t know much about HRT until I joined. Bill Kricker, was instrumental in founding HRT, along with David Dean. The agenda was very much about shared learning based on data-driven benchmarking and collaboration to share good practice. There was also the Honour Code, which demanded that we could not use the information to disadvantage colleagues, we could not share with third parties (eg Health Departments), and that Chief Executive engagement was critical. The primary issues of the day were length of stay management and cost containment.
At the time of inception, the concept of Continuous Quality Improvement (CQI) was on the go, but health was not on board except in a few facilities. However we appreciated we all had significant case mix data sets which showed significant variation in some parameters such as Length of Stay and yet this data was only being used for statistical reporting. We also recognised hospitals did not own data and governments would be embarrassed politically if analysis was published. Hence code names for facilities, confidentially agreements and 3rd party analysis. Examination of variation was the focus but it was all about “why”? and not: “who is good and who is bad”. The focus was on what can be learnt so even the best can do better. The rest is history. Once major hospitals in each state and NZ were on board and outcomes were demonstrated the network expanded.
What data was collected and analysed? How did this occur?
The initial data was for inpatients. It included the basic demographic data about each hospital admission together with the ICD codes for the diagnoses and procedures each patient had. All data were de-identified by the participating hospitals. As each jurisdiction had different ways of providing the data, Chappell Dean (the company established to do all the data analysis), had to convert all of the data into a usable format that allowed statistical comparison. This was a significant challenge in the first few years. As so much work was involved to ensure the data was converted into a useable format, (and the different response rates by the member hospitals) the initial reports were done six monthly. For the first couple of years, the Board of Directors met regularly to make decisions as to how the data could be best presented to member hospitals for benchmarking purposes.
Each hospital provided data to David Dean. This was routinely collected data from each Patient Administration System (PAS). Initially, the data were only on activity, but by the late 1990s, data were also being collected on-costs. There was a detailed review of the data on days of admission prior to elective surgery at the first meeting.
Inpatient activity data, coded and classified into DRGs, and also costing data. Much of the early discussion was around data standardisation, particularly as it related to clinical costing. In the early days, clinical costing was in its infancy. Even in Vic, where casemix funding had been in place for 3 years, there was still an array of clinical costing approaches, with cost modelling predominant. Interestingly in later times when IHPA was established in Australia, there was an early independent review of costing systems that showed significant ongoing concerns with standardisation of approaches to cost allocation.
The founders wanted a mechanism to compare clinical outcomes, and to identify and share ‘Best practice’. Until HRT eventuated, every teaching hospital asserted that it was ‘the Australian leader in….” but there were quite a few CEOs who understood this arrogance would soon be proven to be wrong
When you reflect on the organisation now celebrating 25 years, what do you think are the critical issues that HRT has contributed to in health care?
HRT gradually broke down the notion that every hospital was good at everything. David got the data to a point where it was not rationally possible to argue that it was misleading. CEOs and clinical leaders soon realised there were huge gaps between the best and the worst performers, and that the difference was measured in human mortality and morbidity. The non-threatening environment was a crucial element of HRT’s success. HRT clearly has improved clinical outcomes for several generations of patients, possibly particularly in surgery where clinical outcomes are more obvious and measurable. HRT did some great work with intractable issues like ‘bed blockers’ and long length of stay.
The HRT has contributed to a number of areas, including:
- Benchmarking across State boundaries, and then across public/private boundaries. Pre HRT, benchmarking was very limited and crude. There would be the annual reports from the Australian Institute of Health & Welfare (AIHW) looking at a limited number of variables on a state by state basis. Within jurisdictions there was a variety of reports produced by the health department, but this information was not designed to foster improvement. Today HRT has broken down many of these barriers and moved internationally.
- The Honour Code – greatly contributed to the longevity of HRT, along with insistence on the engagement of CEOs.
- Commitment to accurate, timely data and reports that are geared towards operational management decision making and action
- Clinician Engagement. The HRT was a pioneer in recognising the importance of clinician engagement, and early on introduced specialist working sessions to look at particular areas of work, seeking clinician engagement to a) improve the accuracy of the data/information and b) harness their ideas for improvement.
Variation is still an issue if we are to standardise more where it is appropriate but parochialism seems to prevail. The development of the national medication chart was a good example of what could be done.
In the years that I was involved, there were several key issues:
- Improved efficiency of bed utilisation
- Encouragement of improved financial efficiency, although this was limited by the variety of funding arrangements
- A number of clinical programs targeting a more clinical audience
- Improved clinical governance
There have been two major contributions. The first has been the benchmarking of hospital data. When it commenced, it was the first time that useful, standardised data was available to hospital managers to allow them to understand variation in hospital service provision. Not only that, the data was translated into meaningful information that allowed hospitals to think differently about ways in which hospital services could be provided. The second was the opportunity for members to learn from one another. There was a collegial sharing of ideas and innovations that allowed every participant to learn and grow the quality of their services.
I was appointed to my first CEO role and heard about the Health Roundtable and David Dean from Michael Walsh (then CEO of Alfred Health). I heard how valuable it was and wanted to join but the Founding Chapter didn't want more Health Services in their Chapter as they had formed a strong collegiate and trusting relationship with the CEO's in their group. This meant that we needed to challenge the model the Roundtable had at that time. This led to the creation of a second Chapter, The All Stars, and Christine Bennett (CEO of Westmead at the time) and I worked to get it up and running. There was a bit of competition between the founding members and the 'new’ members. It took several years before the Roundtable included other Chapters and expanded membership.
We were regularly discussing succession planning of David Dean as he would regularly suggest he may retire but that went on year after year and he continued.....He was the Health Roundtable and it was unimaginable to have someone else in the role. He had a small very expert team that worked closely with each other but David was the driving force. The new Chapter quickly found its legs and proved to be very valuable for all. Others heard about it and wanted to join and share learnings so further members were accommodated.
What are 3 or 4 future-focused topics that you believe hospitals and HRT members could best explore? Why are these important?
HRT has made many incremental changes over the years to better serve its members. The time is now right for an exponential change. Virtually all Australasian jurisdictions now do some form of benchmarking of their hospital data. Many also have centres to improve clinical performance. In many cases, these jurisdictional activities have built upon the activities initially started by the HRT. Further, the impact of COVID-19 has meant that member hospitals and health services of HRT are now expecting different types of support.
The peer groupings could be better fine-tuned to allow for hospital variation - e.g. a hospital may be compared to one group for its renal dialysis services, another for oncology services, and another for paediatric services. The most important exponential growth must relate to sharing innovations. The HRT would benefit by becoming aware of all of the best practice activities that are occurring. This means active surveillance by its staff, and not simply a reliance on members sharing innovations at HRT workshops.
My suggestions are:
- Sharing of RCA investigation results, with an aim towards better clinical governance
- Improved utilisation of outpatient and community strategies, to reduce hospital utilisation
- The risks and benefits of general medicine vs subspecialty medicine
There are several! Including:
- Digital transformation, telehealth etc and the associated work of clinical informatics, and beyond this, practical applications for artificial intelligence
- the shift of work out of the hospital and into a community setting
- Best practice in managing chronic conditions and old age in 2050. There could be a HRT for aged care, including home support right through to residential aged care
- Primary care and its interface with the rest of the system. NZ more advanced in this regard than Australia. As we move to ubiquitous EMR then the role of Primary Care as coordinator/navigator becomes more pronounced.
Basic metrics about clinical outcomes, standardised mortality rates and so on remain important as a fundamental driver ongoing quality improvement for hospital services - this really does affect people’s lives. HRT could probably do more proactively to identify areas for improvement in each hospital -‘the low hanging fruit’ and also where major morbidity or mortality deviates from expected levels. Pointing out the difference between a hospital’s clinical outcomes and (say) 25th percentile performance could be a driver of change for clinicians and administrators alike. Maybe it’s time for ‘name and shame’ for those at the bottom end of the performance scale? HRT also needs to open its eyes to the available data in the private sector, where I suspect there are glaring anomalies in performance (by both parties).
HRT could also do more to assist CEOs and administrators to identify underperforming individual clinicians. It’s tempting to mention measurement of patient functional outcomes, and while theoretically attractive, there is so much to do in raising standards of clinical practice that anything more esoteric probably has to wait. Mental health seems to remain an unmeasurable quantity in terms of patient outcomes - this is an area which HRT should address, maybe in conjunction with the relevant College.
What advice or suggestions would you provide to hospital staff to maximise their learning experience and the support from HRT?
Understand the data – to spend time analysing performance against at least second quartile standards, and learn how to work with clinicians to bridge the gap.
This is as much an exercise in communications as it is in clinical practice. HRT members - right down to department / clinical discipline level - should be open to external assistance from skilled change analysts and advisors.
There needs to be support and collaboration from the Health Departments in each State so that individual Chief Executives do not prevent participation.
Participation! Openness and willingness to share and learn from others.
HRT leaders should know about, and be able to share, the best practice services that are occurring in Australasia. This is similar to what Vizient does for its member hospitals in the USA and the Australian Jurisdictional Quality Improvement / Excellence bodies are also doing now – but usually only for selected topics of interest.