Hospital Reform

Implementation and Evaluation

Dr Hong FUNG
28 January 2010

Health System Goals

Health status Financial risk protection Public/ patient satisfaction

(WHO, 2000)

Safety

Timeliness (Access)
Crossing the Quality Chasm: A New Health System for the 21st Century
Institute of Medicine, 2001

Modern Health Systems

Institutions
National policy Regulation Financing

Providers
Doctors Nurses

Organizations
Hospitals Clinics

Five Control Knobs

Macro-organization Financing/ resource mobilization and pooling Provider payment Regulations Social values/ persuasion

(After Hsiao)

State Authority in Health Sector

Command & Control Entities with full state ownership Entities with full state ownership but managerial independence Private not-for-profit entities with statutory responsibilities Private not-for-profit entities without statutory responsibilities Private for-profit provides under tax-funded or statutory social insurance systems Steer & Channel Private for-profit companies

Marketizing Reforms
Separation of payer and provider Continued funding, contracting or purchasing by government Quasi-markets/ internal market/ regulated competition Autonomization/ corporatization/ privatization

Critical Factors for Organization Reform

Budgetary Unit B Decision Rights Vertical Hierarchy Autonomized Unit A Corporatized Unit C Privatized Unit P

Management Autonomy Non Budgetary Revenues Private Owner Rules, Regulations and Contracts Specified, Funded and Regulated

Market Direct Budget Allocation Exposure Residual Public Purse Claimant Accountability Direct Hierarchical Control

Social Functions Unspecified & Unfunded Mandate

Incorporating Modern Management

Introducing entrepreneurship Management decentralization Self-governing hospital structures Performance related payment Quality and outcome culture Market competition Increased technical efficiency

Summary of Recent Health Reforms

From Preker AS and Langenbrunner JC, 2005

From Policy to Implementation

Three Key Strategies

1. Enhancing government stewardship 2. Strengthening hospital governance 3. Developing a system of performance management

Government Stewardship
The ultimate responsibility for the overall performance of a countrys health system must always lie with government.
(WHO, 2000)

Stewardship is the careful and responsible management of the well-being of the population.

The Role of Government

3 core tasks of Stewardship (WHO, 2000)
Formulating health policy Regulating the health sector Collection and using intelligence

Strategies for collecting revenues and pooling of funds Effective resource allocation and/ or purchasing

The Evolution of Governments

Row less, steer more Steering = making strategic policy decisions and establishing the vision Rowing = operational service delivery and implementing the vision

Regulation & Strategic Purchasing

Regulations
Regulation as a process to ensure compliance with stated policy objectives within a defined framework of action. Regulations on Quality and effectiveness Patient access Provider behavior Payers Pharmaceuticals Physicians

Examples in HK
Centre for Health Protection Centre for Food Safety Registration of Chinese Medicine practitioners and herbal medicines Pharmaceuticals .. .. Accreditation of hospitals Health insurance products

Strategic Purchasing
The proactive or strategic allocation of resources in the light of health gain, responsiveness and efficiency goals. involves a continuous search for the best ways to maximize health system performance by deciding which interventions should be purchased, how, and from whom.

What is involved?
Splitting purchaser from provider Separating of governance of funding agency Active process of contracting, purchasing and commissioning Focusing on outputs and outcomes Capacity building in regulation and coordination of non-governmental providers

Examples in HK
Using Hospital Authority as a platform Setting pricing benchmarks Purchasing of care from private sector
Cataract surgery Primary care in deprived areas Shared care in chronic disease management Diagnostic radiology

Pay-for-performance mechanisms Using Electronic Health Records as a vehicle Shared electronic patient records (ePR)

Hospital as Reform Targets!

Local boards play a key role in health sector reforms

Hospital Governance
2 levels of governance Corporate governance Clinical governance

Corporate Governance
The processes, and the related organizational structures, by which organizations are directed, controlled and held to account.

(HKSA, 2004)

3 Basic Principles
Openness
Disclosure of information and communication Decision making processes and actions

Integrity
Straightforward dealing and completeness Honesty and objectivity

Accountability
Stewardship of public funds Performance

4 Dimensions
Standards of behavior Organizational structures and processes Risk management and control Accountability, reporting and disclosure

7 Principles of Great Governance

Understanding of and commitment to the mission Articulate and embrace the core values Clear on fiduciary role and basic responsibilities Strict adherence to conflict-of-interest policies Recruitment, education, self-assessment of members and accord priority to goal setting processes Create a respectful and collegial governance environment Respect the distinction between the roles of governance and management

Clinical Governance
Clinical Governance is the system by which the governing body, managers and clinicians share responsibility and are held accountable for patient care, minimizing risks to consumers and for continuously monitoring and improving the quality of clinical care.

Australian Council on Healthcare Standards ACHS News 2004; 12:1-2

Integrating approaches of clinical governance

Copyright 1998 BMJ Publishing Group Ltd.

Clinical Governance Framework in NTEC

Process and Structure Performance Quality & Risk Process Values and Beliefs Infra-structure Coherence Engagement & partnership Culture

Accountability Structure in NTEC Hospitals

Hospital Chief Executive

Hosp Q&RM Coordinator

Chief of Service

Clinical Governance Coordinator Dept Q&RM Coordinator

Key Responsibilities in Clinical Departments in NTEC

Chair of Clinical Governance Dept Q&RM Coordinator

Information & Performance

Clinical Quality

System & Risks - Manpower - Equipment - Workload - Workflow/ processes - Incidents

- Performance reporting - Disease coding - Data quality - Web communication

- Clinical protocols - Clinical standards - Clinical audits

A System of Performance Management

The proactive measurement of performance for securing health system improvement and accountability It involves monitoring, evaluating and communicating the extent to which various aspects of the health system meet their key objectives A built-in system of evaluation against health system goals

The Balanced Scorecard

From: Kaplan & Norton, The Balanced Scorecard, 1992

Frameworks of Performance Measurement

The first requirement of any performance measurement system is to formulate a robust conceptual framework within which performance measures can be developed.

Smith, 2008

Framework of Performance Measurement in Australia

1st Tier: Health outcomes
How healthy are we as a nation?

2nd Tier: Determinants of health

Are we trending towards or away from health?

3rd Tier: Health system performance

Are our acute, primary care & population health interventions of the highest quality at the least cost?

4th Tier: Health system infrastructure and community capacity

Is our system infrastructure sustainable in to the future?

Dimensions of Health System Performance (Australia)

Effectiveness
Service, intervention achieves desired results

Appropriateness
Service provided is relevant to patient needs & based on established standards

Safety
Potential risks of an intervention or the environment are avoided or minimized

Capability
Individual knowledge/skills appropriate to care/service provided

Continuity
Ability to provide uninterrupted, coordinated service across organizations & over time

Accessibility & Equity

Ability of patients to obtain service at the right place & time, based on needs and is equitable

Acceptability
Service provided meets expectations of patients, community, providers & paying organization

Efficiency
Achieving desired results with most cost effective use of resources

HAs Service Performance KPIs

Access
1. Waiting Times
A&E WT New case booking for SOP services

Quality
1. Appropriateness
Admission rate for AED pts

Efficiency
1.

Drug consumption
Ca-channel blocker/ ACEI/ Inhaler for asthma/ Big gun/overall antibiotics

2. Safety
Infection rate Unplanned readmission rate for General IP

2. 3.

Day surgery plus same day surgery GOP services

% of GOP attendances for chronic diseases

3. Service Coverage
CGAT & VMO scheme

4. Disease Specific Indicators 4.

Stroke Fracture Hip Cancer Diabetes Mellitus (DM)

Bed Management
Ratio of excess beds to 1000 in-use beds IP occupancy rate (MN) General IP ALOS

Incentives for Quality Improvement in HA

12 key performance indicators
Accessibility (waiting time) Appropriateness of care Patient safety Clinical outcome

Achievements against international or local benchmarks Improvements towards targets

Thank you!