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The Challanges of Clinical Leadership in Ireland
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The challenges of Clinical The challenges of Clinical Leadership in IrelandLeadership in Ireland
Áine CarrollNational Director
Clinical Strategy and Programmes DivisionHSE
Why Reform? Government policy (Future Health, Healthy
Ireland…) Need to improve service delivery
Integrated models of care Shift focus towards health & wellbeing
Existential economic challenge for health systems People who use and work in the Health Service
expect things to improve
Department of Health
Health Commissioning Agency
· Healthcare needs analysis· Models of care· Core service definition · Quality & Standards· Commissioning Intentions· Contract Management
· Performance Management
Regulators· HIQA· MHC· IMB
Health Service Providers
Hospital Groups Community Health Care Organisation
Grant Funded Agencies Primary Care Providers
HIQA · Licensing and compliance monitoring of
residential and specialist ambulatory services for children, older people and people with disabilities.
· Develop standards. · HTAs to evaluate new technologies and · Advise on the collection and sharing of
information across the healthcare services.
National Information and Pricing Office· Separate pricing from
purchasing / commissioning· Hospital Inpatient Enquiry
Scheme (HIPE) (maintained by ESRI)
· National Casemix Programme
Patient Safety Authority· Subsume National Clinical
Effectiveness Committee (NCEC)
· Sets guidelines for eligibility for treatment under UHI
Support Services· Strategy to be developed · Shared Services· PCRS· Electronic claims
management system· Finance Operating Model· MTPF / UHI eClaims · HR· ICT (eHealth)· Audit· Parliamentary Affairs· Informatics
Healthcare Commissioning Agency· Subsume HSE service directors· Convert National Services Framework into
detailed performance targets· Commission services through MFTP and block
allocation contracts· Subsume NTPF and SDU· Divest some responsibilities on move to UHI
Public Hospitals· 6 adult and 1 Paeds hospital groups· Each with a hub that is an academic
medical centre· 48 hospitals (29 statutory and 16
voluntary acute)· Mix of public and private carePrivate Hospitals· Role of private providers under UHI to be
defined· 21 private hospitals (acute and mental)· Approx 3,500 beds· 1 in 6 of all acute beds
Community Health Care Organisations· Successor to ISAs· Review of role of 17 ISAs
(32 Local Health Offices)
Grant Funded Agencies· Status and commissioning
of grant funded agencies to be defined
· Over 2000 separate grant funded agencies
Primary Care Providers – Public and Private · GPs· Dentists · Pharmacists · Opticians
Professional Regulators· Medical Council· An Bord Altranais (Nursing &
Midwifery Board of Ireland)· Dental Council· Pharmaceutical Society of Ireland· Health & Social Care
Professionals Council
Other Regulators· HIQA (see above)· Mental Health Commission· Food Safety Authority of Ireland· Irish Medicines Board· Health Insurance Authority
Professional Bodies· RCSI· HMI· Therapies· IADNM· RCPI· ICGP· Forum of Post Graduate Training
Bodies
Other Agencies· NTPF (move to HCA)· Health Research Board· Irish Blood Transfusion Service· Safefood· Institute of Public Health
Commercial State Company· VHI (UHI provider)
Emerging Future Health System
UHI Providers· Claim settlements
· Payments
Support Services· System wide common services· Shared services & PCRS· MFTP / UHI Claims
National Pricing Office· Price Informatics· Tariff Setting · Pricing
Economic Regulation
Patient Safety
Authority
Health Insurance Authority
Paym
entSLA Cont
ract
&
Perfo
rman
ce M
gt
Perfo
rman
ce
Repo
rting
Paym
ent f
or it
ems
not
cove
red
by U
HI
Ensure quality and safety standards across system
Reco
mm
ends
tarri
ff
Tariffs & Pricing
Polic
y
Perfo
rman
ce R
epor
ting
Cost
Dat
a
Approves payment
Funding
SLA
Regulates the market
Payment
Ensures operational effectiveness and financial stability.Authorises Trust status (tbc)
Clai
ms
Paym
ents
Ambulance
Key to text· Current organisations· Significant changes
Representative Groups· IMPACT· IMO· INO· IHCA· SIPTU· Unite· IDA· PNA· TEEU
Employers · Google, HP, etc
OUR Enablers and Challenges
Thousands of dedicated and able people across the health service
Many major and minor improvements achieved – Cancer, Stroke
Many people have a good experience of the health service
Elements aligned Great desire among people to see
change
Poor history of working in a co-ordinated way – fragmented; fractured
High levels of distrust and apprehension
Sense of lack of connection between the top and the bottom
General lack of credibility Have we lost sight of our purpose? ‘We have heard it all before’
Enablers Challenges
Rules for transformation Effective leadership Data feedback Honour the work Engage clinicians Involve patients and families
Large-System Transformation in Health Care: A Realist ReviewALLAN BEST, TRISHA GREENHALGH, STEVEN LEWIS, JESSIE E.
SAUL, SIMON CARROLL, and JENNIFER BITZ1 The Milbank Quarterly, Vol. 90, No. 3, 2012 (pp. 421–456)
IOM Aims of redesignTimely CareEfficient CareFamily-Centred careEffective CareEquitable CareSafe Care Priority #1
National Clinical Programmes:Mission & objectives1. Improve Quality2. Improve Patient Access3. Value
Key principles1. Clinically led – empower clinicians to
lead the change2. Structured programme management
approach3. Nationalise existing best practice4. Engage Patients5. Align stakeholders – Government,
Management, Colleges, Unions, Patients, etc
Why? Partnership between HSE and
Clinicians through the Forum of Postgraduate training colleges
Partnership with Irish Association of the Directors of Nursing and Midwifery and the Therapy Professions Committee
Partnership with patients
Some Achievements To DateNational Clinical Programme for Acute Medicine:• Introduction of the National Early Warning Score (NEWS): received public service excellence award from Taoiseach• Total length of stay reduced by 21% between 2005 and 2012 with the introduction of Acute Medical Assessment Units in every acute
hospital• Overnight length of stay reduced by 8% between 2005 and 2012
National Clinical programme for Epilepsy Received an international nursing award for its description of the new national epilepsy service of Ireland (the ‘limelight’ award is part of the
international care challenge series by Sanofi which allows nurses from around the world showcase nursing innovations)
National Clinical programme for Rheumatology/MSK• Physiotherapy led Musculo-skeletal clinics are reducing waiting lists by up to 70%• 10,000 new patients triaged and treated from orthopaedic and rheumatology waiting lists in one year
National Clinical Programme for COPD• COPD Outreach Model of Care and Pulmonary Rehabilitation Model of Care, Bundles of Care, and patient information materials developed
and issued for adoption.• Average Length of Stay (AvLOS) reduction from 9.1 days in 2009 to 7.6 in December 2012• Pulmonary rehabilitation available in 37 sites. Access to Pulmonary Rehabilitation in 56% of sites (2012) has exceeded the target set
(25%). Further work ongoing to target areas without access.
National Clinical Programme for Medicines Management• The Medicines Management Programme has identified an additional 2 drugs, ace inhibitor (Ramipril) and angiotensin 11 receptor
(Candesartan) as part of the ‘Preferred Drugs Initiative’. The Programme is aiming to secure €20 million in savings in 2013.
Some Achievements To DateNational Clinical Programme for Stroke 27 out of 28 hospitals admitting patients with stroke requiring acute care now have a stroke unit. This is an increase from 18 in July 2010. Thrombolysis available in all model 3 and model 4 hospitals either directly or via ambulance access protocols. Thrombolysis rates have increased from 2.4% in 2007 to 9.5% in 2013 exceeding targets and leaving Ireland with one of the highest rates
in the world (UK is 5%, Sweden 6.6% and USA 2.4%) 1.5% increase in patients discharged to home in 2011 (110 patients/yr, 2 patients/week) 2% decrease in case-fatality in 2011 i.e. 70 patients/yr. This was also sustained in 2012. 2.9% decrease in stroke Nursing Home admissions i.e. 150-160 patients/yr
National Clinical Programme for Diabetes Diabetes Retinopathy Screening has commenced in quarter 1 of 2013 and this aims to screen 30% of the diabetic population in 2013. A national model of care to deliver CS11 therapy to children with type 1 diabetes under 5 years of age has been developed and
implemented.
Retrieval & Transport Medicine• Neonatal retrieval extended to 24/7 nationally in 2013• Paediatric retrieval due to commence a 5 day daytime service in 4th quarter 2013• National model for adult retrieval designed to support hospital groups. Implementation planned for 1st quarter 2014 in Dublin, Cork and
Galway providing a 7 day daytime service
National Clinical Programme for Audiology • National screening of 99% children within 4 weeks of birth
National Clinical Programme for Acute Coronary Syndrome• 4 24/7 PCI centres operational
Don Berwick
Problems Lack of integration Resources Hierarchy Disconnect between strategy and operations HR Finance Procurement Data management
Reform CSPD Programme Structure
Director General
CSPD Team
Forum PGTBI
Project Sponsor
Systems Reform Group
Training Bodies
Project Team
HR & Finance
Est. end ‘13
“Establish the NCP as the Clinical Design Authority for Health Service”
Governance of NCSP: The Health Services Clinical Design Authority
Stakeholder Group
Enabling Functions: HR, ICT, Finance, Performance Assurance.
Structured interface
Stru
ctu
red
inte
rfac
e
Principles of Health and Well being
User and Provider Integration and Standards
Educated, Healthy
Supported
Temporary/ Transient Low- Medium Support &
Management.
Temporary/ Transient Medium to High Support & Management.
Rehabilitation or Permanent Support.
Enablers; Information, Resource, Tools.
Communication and Stakeholder Engagement in Care Planning
Dignified, Healthy, Safe Living
Draft Generic ICP Framework
Emerging Themes
Health & Wellbeing
Primary Care
Acute
Hosps Social Care Mental
Health
ICPs as related to Service Divisions- Horizontal Integration
Health & Wellbeing
Primary Care
Acute
Hosps Social Care Mental
Health
Programmes
ICPs – Vertical Integration e.g. EWS
Health & Wellbeing
Primary Care
Acutes Social Care Mental Health
Single Assessment Tool
Integrated Community and Acute Model of Care
Dementia Care
Delayed Discharges
Positive Aging
Rehabilitation
Older Persons
Don Berwick's top ten tips1. Patients first2. Stop restructuring3. Strengthen the local health care systems– community care systems–as a
whole4. To help do that, reinvest in general practice and primary care5. Don’t put your faith in market forces6. Avoid supply-driven care like the plague (institutional self interest)7. Develop an integrated approach to the assessment, assurance, and
improvement of quality8. Heal the divide among the professions, the managers, and the government9. Train your health care work force for the future, not the past10. Aim for health not care
Managers and Clinicians
We are stewards together of healthcare resources
The needs of the patient come first
“We must be the change we wish to see.”
Ghandi
Thank you