Patient flow indictment on system, prof says

Robin Gauld
Robin Gauld
Dunedin Hospital’s issues with patient flow, which seem to have changed little in more than a decade, are an indictment on the way the healthcare system works, Prof Robin Gauld says.

His comments followed Southern District Health Board chief executive Chris Fleming saying this week high numbers of stranded patients and blockages in the flow of patients through Southern hospitals could be remedied if clinical leaders embraced the need for changes.

He cited discharging more patients by lunch-time to free up beds for later in the day and early senior assessment in the emergency department as examples of the changes required.

Such changes would make a real difference in clinical care, patient outcomes and "most likely would reduce wasted resources", Mr Fleming said.

Prof Gauld, who is now dean of the business school at the University of Otago, recalled being in Boston in 2009 as a Harkness healthcare and policy practice fellow, commenting on concerns then about a Dunedin Hospital ED-led project called "Putting our Patients First".

That pilot project, which began in 2008 as part of a national project called "Optimising the Patient Journey" was supposed to both save money and result in better care for patients.

The pilot’s lead clinician, emergency medicine specialist Dr Tim Kerruish, told the then Otago District Health Board in 2009 there was a lack of vision to support the improvements and he was concerned that the moves could founder in the existing hospital culture.

Prof Gauld said then that the board needed to drive quality improvement measures and prompted more controversy by saying staff who insisted on doing things as they always had should "grow up".

Transforming the hospital culture was a board and leadership issue, he said at the time.

This week, Prof Gauld said what appeared to be little improvement since then was extraordinary and reflected the lack of basic leadership and management training within the clinical workforce.

Prof Gauld has been a long-time critic of the DHB set-up, which he says should be done away with.

He says there is little evidence the governance boards on DHBs are effective, the system is administratively clumsy, and boards are accountable to the government, not voters.

Public hospitals and associated services should be retained but run by a manager who was part of a national team, with a focus on consistency, collaboration and service quality improvement. He would like to see existing alliances between DHBs and primary health care organisations (PHOs) strengthened and used as the foundation of the health system, with decisions made on clinical considerations, not whether a decision might be palatable.

Health professionals should be empowered through the alliance, working in partnership with each other and patients to design the system and services, and allocate funds to the right place, into community settings where possible.

The Health and Disability System Review panel led by Heather Simpson is due to make its final report this month, but the interim report contained no recommendations, so it is not yet known if radical changes will be proposed.

This week, the board’s hospital advisory committee was briefed on plans to improve flow of patients through ED by specialist services executive director Patrick Ng.

This included a "fit to sit" extension to the Dunedin Hospital ED, which is expected to be in place before winter. This area would be fitted out with chairs, to be used by people who did not need to be admitted to hospital after their treatment and before they left the hospital.

The board is also developing plans for an up to 20-bed $2.5million medical assessment unit next to the ED, for patients who need a stay of about 24 hours, rather than full admission to a ward.

The idea is that this would move patients through the ED faster and fewer hospital beds would be required. This would involve increasing the number of senior doctors in ED from four to six, along with some reconfiguration of nursing and increased spending on allied health workers.

The plans for this are expected to be brought to the board for discussion in two months.

Comments

We'd really like to help with the design, the ergonomics, the models of practice, but, it's the foot, or something else, you see. Usually, we're supine.

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