26/27 June 2008 - Brisbane

1. Clinical Organisation Profile“moreover it was an operational philosophy that everyone knew and understood only in part” Tom Clancy, Debt of Honour Presenter: Grant HowardHospital: ArtemisDr Grant Howard, GM Operational Performance and SupportContact: HowardG@waikatodhb.govt.nz 26/27 June 2008 - Brisbane

2. Waikato District Health Board, Health Waikato • Health Waikato: Provider Arm of the DHB • Five Hospitals, Mental Health, Community and Public Health. • 5500 staff (that we know about) • WDHB budget: $800 M, Health Waikato: $ 560 M • Waikato Hospital: 600+ beds, 198 000 bed days Tertiary Hospital Teaching Hospital

3. KEY PROBLEM Symptoms • General Frustration • Goals are not clear, at all levels • Poor Performance • Surprises resulting in crisis management • A confused organisation • 101 KPIs for a clinical nurse leader • No culture of accountability • Inward Looking • Many functional add-ons • Committees, groups and task forces • A focus on cost reduction rather than strategic improvement • Lack of • Information • Transparency • Tools Diagnosis • The Organisation is ideal for delivering the results it is currently delivering. However it is not fit for high performance • Goals are not clear • The organisation is more an outcome of history than purposive design • Accountability not clear or enforced • Strategic and operational goals and processes do not align with the accountability roll up • Clinician involvement is too narrow • Operational Management processes are poor • No clear strategic improvement plan

4. Accountable Organisations: How ? Management 101, the bit they don’t tell you……… • Recognise basic units of labour – teams / RC’s • Provide a construct for the teams to be understood and understand their relation to each other. • Make the construct: • Visible, easy to communicate and understand • Universal (coffee cart = clinical unit = radiology) • Unifying (doctors = managers = cleaners) • Facilitate operational activities • operational planning and budget • Reporting and forecasting

5. High Performance Organisations - Design Principles • For a resource centre manager/ supervisor to work effectively they must clearly know • What they are accountable for and to whom • The task they have to perform • What their output should be (Activity ,Quality ,standards ,etc) • What their output is (Activity ,Quality,deviation from standards etc) • They must know who is accountable to them and what for • What their resources are • What their Operational Plan is 5

6. Operational Framework

7. Clinicians / RC’s / Performance • Given the 2 roles of clinicians, there are also 2 types of resource centres: • Departmental Resource Centres • Performance & Revenue Resource Centres • The Departmental Resource Centres are the predominant resource centres in an organisation. • The Performance &Revenue Resource Centres are related to episodes, revenue and the totality of the clinical services delivered to a patient

8. Operational and Professional Responsibilities Operational Plan: Budget Price-volume schedule WIES/ CWD Revenue / Expenditure / Contribution Capital and Infrastructure Cost –Quality relationship Performance & Revenue RC Patient throughput and outcomes ICD’s and DRG’s Clinical Plan: Length of stay Care pathways New technology or procedures Standardisation Competency Credentialling Quality: re-work / scrap / 1:10:100 rule

9. Structure and Operational Function • A structure exists down to the resource centre level • The structure should be representable in the operational construct: • Resource Centres • Group Tree • Chart of accounts in the General Ledger • All of the processes that apply to any RC of any kind, apply to all: • Operational Plan (Clinical Operational Plan) • Budget (Clinical Stream Budgetting) • Reporting Actual vs Plan • Manage the plan (100 hrs a year rule) • Professional and Operational responsibilities (Finance dotted line lesson)

10. Tools - This is no org chart ! Problem: These concepts are great in theory, but how do you develop a tool that : • Gives direction: Educate and communicate • Gets clarity about who works where and for whom – clarifies what that person is accountable for and to whom: • Describe the organisation to RC level • Lines of communication • Delegation of authority • Gets things to line up - Integrate the structure into the business management function: • Group tree • Chart of accounts • Reporting tools • Facilitates 2 way communication Solution: The Clinical Organisation Profile

11. Commonplace ? • We had to carve the document out of Microsoft (Word) stone • Commercial taxonomies = 0 • Understanding: Avoiding the bullets “The organisational profiles are difficult to follow, why does the document have all these sub sub numbering systems?? What do they relate to? it seems much bigger and harder to read than it could be, especially in the middle section.” “The FTE status is incorrect as we also have contracted staff on board and why is it necessary to supply the FTE status?” “It is our recommendation that this document should be put on hold until the Peoplesoft software component that will be able to do the function of organisational structure is in place.”

12. Evolution of an Accountable Organisation: A document and a journey • “I have not read it, something like that would bore me to tears in 10 seconds” An Accountable Organisation Version 5: % Complete Version 4: Nurse Practitioners, Allied Health, Midwives Dangerous slog Version 3: Performance RC’s Version 2: Structure and Assumptions Start: Taxonomy, light bulb moment Time

13. Thank You

14. For Information: What might an accountable structure look like ? Management Executive Committee Director Medical Services or Equivalent Clinical Business Unit Division of Surgery Unit or Service Manager • Operational Responsibility • Performance Plan • Budget • Change Management : eg Business Case • Clinical Plan • Good Practice • Equipment • Future directions Operational Professional Unit Clinical Director (eg:orthopaedics) 100hrs rule