john dalli - report on mater dei for pm

8/13/2019 John Dalli - Report on Mater Dei for PM

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Report on Mater Dei John Dalli

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Table of ContentsFORWARD...........................................................................................................................................................4

SUSTA!A"#T$ OF T%& %&A#T% S&CTOR......................................................................................'

(AT&R D& %OS)TA#..................................................................................................................................*

(A!A+&(&!T..................................................................................................................................................,

JO%!S %O)-!S R&)ORT 2011 ..................................................................................................................

F!A!C&............................................................................................................................................................../

!FOR(ATO! T&C%!O#O+$................................................................................................................11

%U(A! R&SOURC&S....................................................................................................................................12

!&!TOR$......................................................................................................................................................14

PROCUREMENT................................................................................................................14PROCUREMENTOFSERVICES............................................................................................15OUTOFSTOCKPHARMACEUTICALS...................................................................................16

OTHERCONTRIBUTINGFACTORS......................................................................................17INVENTORYINHOSPITAL..................................................................................................18ENHANCINGCOST EFFECTIVENESSINTHE SURGICALDEPARTMENTS.....................................19

C#!CA# )RACTC&S.................................................................................................................................21

T%& #& OF CAR& S %+% "UT T S DSOR+A!S&D.........................................................21

WA$ FORWARD..............................................................................................................................................23

REFOCUSINGTHE ROLE OFTHE FOUNDATIONOFMEDICALSERVICES...................................2ACHIEVING!BEST"IN"CLASS# PATIENTCENTRIC$UALITYSERVICESPROVIDER......................24DEVELOPMENTOFA!MANAGEMENT# INFRASTRUCTURE.......................................................26EVOLVINGHOSPITALSERVICEDELIVERYINTOAH IGHVALUEADDEDNE%ECONOMICSECTOR..................................................................................................................................... 27

R&T%!-!+ W#!&SS T%& FUTUR& OF %&A#T%CAR&.....................................................2

T%R&& ARU) S)&CA#STS S%AR& T%&R SO! OF T%& FUTUR& OF %&A#T%CAR&

D&S+! %TT)55WWW.ARC%DA#$.CO(543//5.........................................................................2

LOOKINGAHEAD& A FUTURIST'SV IE%OFHEALTHCARE( IANMORRIS"HTTP&)) IANMORRISON.COM)LOOKING"AHEAD"A"FUTURISTS"VIE%"OF"HEALTHCARE)..................28A PARADIGMCHANGE......................................................................................................28INNOVATION...................................................................................................................28

A S(ART SO#UTO!....................................................................................................................................31

A %&A#T% S&RC&S &CO!O(C S&CTOR.......................................................................................32

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Sustainability of the Health Sector

The #a%or issue in the health sector throu"hout the world is the sustaina!ilit of the

health sste#s that have !een developed over the past decades and that are !ased on

solidarit.

Scientific pro"ress in resultin" in !etter #edicines and procedures that are increasin"

health costs even #ore as patients e(pect the !est that is availa!le. The !etter cures

and care co#e at increased costs& while& coupled with a !roader covera"e of the

population resulted in an a"in" population that is increasin" the de#and for health

e(ponentiall.

However& resources are li#ited& and therefore s#art solutions need to !e found to

finance and deliver the health sste# that the population e(pects. 'e own it to

future "enerations that the can also rel on a hi"h ualit& accessi!le health service.

The #a(i# has to !e that announced ! the 'orld Health 0r"anisation,

Health is a state of complete physical, mental and social wellbeing and not merely

the absence of disease or infirmity.

and

Hospital management has a responsibility to the community to provide health care

service that is at an acceptable level of quality but at the least possible cost.

A s#art health deliver should !e !ased on an appropriate #i( of prevention& self

care& co##unit care& pri#ar care& and a cost effective acute patient centric tertiar

health sste#& supported ! adeuate reha!ilitation and "eriatric facilities.

This report focuses on Mater Dei Hospital& and the restructurin" that #ust !e done

so that proper care is "iven within an adeuate ti#e fra#e at an efficient cost.

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(ater Dei %os6ital

A review of the processes and operations which have !een allowed to develop in

Mater Dei over the ears shows a tale of ineffective #ana"e#ent resultin" in

inefficienc and waste. It reveals a state of pla where coherent political and

ad#inistrative leadership is stri)in" ! its star) a!sence. The result is a state of

anarch where ever sta)eholder within Mater Dei Hospital 5MDH6 has esta!lished

its own 7territorial8 rules at the detri#ent of a patient centric ualit health care

e(perience of e(cellence across co##unit care& acute& reha!ilitation and

outpatients value chains.

'hat is distressin" of the state of pla is that there is no rational reason of wh

Malta8s health sste# with MDH& currentl& the )ernel of such a sste# is in the

level of disarra that it is. Malta& has onl recentl& invested #illions in a new acute

hospital& sophisticated and leadin" ed"e health technolo"& and is currentl in thefinal sta"es of co##issionin" a state of the art oncolo" hospital. This invest#ent

constituted a uniue opportunit for the political& ad#inistrative& and health service

professionals and service providers to co#e to"ether and re9desi"n the paradi"# for

health service provision in Malta. +ro# first hand e(perience I can state that the

#ain underlin" reason for the invest#ent in the :ew Hospital was this paradi"#

chan"e. That this has not happened is scandalous.

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(ana7e8ent

The sin"ular #ost disconcertin" ele#ent that co#es out fro# the review is that no

invest#ent was #ade to euip hospitals& which are co#ple( or"anisations& with

e(perienced talented #ana"e#ent at all levels and in clinical as well as

ad#inistrative positions. This report is uneuivocal, an refor# of MDH and

related hospitals within the health service deliver value chain will fail unless

*overn#ent is read to invest in a co#prehensive and e(tensive #ana"e#ent

infrastructure across senior and #iddle #ana"e#ent levels in ad#inistrative as well

as clinical positions.

Malta has li#ited& if at all& e(pertise in hospital #ana"e#ent and no effort was #ade

to i#!ue the hospital with the specialised #ana"e#ent s)ills reuired to or"anise

and run health operations li)e Mater Dei.

+ro# personal e(perience I can sa that an effort was #ade in 211 with Johns

Hop)ins& a reputa!le ?S hospital to participate in the reor"anisation and

#ana"e#ent of the hospital with the o!%ective of overlain" a professional sste# in

Mater Dei and inse#inatin" an international Health Service as a new econo#ic

activit for Malta. This initiative was dropped in 21/1 !ut Johns Hop)ins was later

as)ed to produce a report on Mater Dei with reco##endations 5see !elow6

Deficient #ana"e#ent is e(acer!ated ! the continuous political involve#ent ever

since the openin" of MDH& so#eti#es even !passin" the Health Ministr. This

rendered the #ana"e#ent of the hospital as ineffectual accessories.

If the hospital is to function to an accepta!le level of efficienc& efficient

#ana"e#ent& with full authorit to decide on the structure and processes of the

hospital& 5within the political o!%ectives of the "overn#ent and the #inistr6&

without an interference fro# outside #ust !e installed.

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Johns %o69ins Re6ort 2011

In Au"ust 21//& Johns Hop)ins was co##issioned to analse the situation at Mater

Dei Hospital and to #a)e reco##endations for reor"anisin" its process for a #ore

efficient& cost effective service. This report was updated with #inor a#end#ents

and resu!#itted on the th June 21/2.

Anne( / shows the e(ecutive su##ar of the report& which has a detailed analsis of

the processes at Mater Dei and which #a)es reco##endations !ased on the

international standards and !ench#ar)s which are a "iven in hospitals of repute.

This report cost the Malta *overn#ent around /.3 #illion and althou"h it is not

infalli!le& it does contain #assive insi"hts into the operations at Mater Dei and what

are the actions to !e ta)en to i#prove the outco#es in the areas of patient safet&

"overnance& clinical practices& hu#an resources deplo#ent and a "eneral up"rade

of the i#a"e of the hospital.

It does not see# that a proper follow up was #ade on this report& althou"h the

#ana"e#ent of Mater Dei Hospital tried to address so#e issues on which the could

e(ercise so#e control. Anne( 2 shows the actions ta)en on the report& and the areas

which have not !een addressed at all. I !elieve that this report is a ver "ood !ase

for the discussions of a root and !ranch refor# of the practices at the hospital so that

the Maltese citien is "iven a patient centric ualit health care e(perience of

e(cellence.


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Finance

The financial sste# is tanta#ount to !ein" non e(istent. At Mater Dei& there is a

one entr !oo))eepin" sste#& which is not covered ! an accountin" policies that

should !e the !asis on which financial transactions are to !e recorded. There are no

proper !oo)s of account& no proper records of a#ounts that are due or owin" to the

hospital& no control of pa#ents that are #ade& and no #ana"e#ent accounts that

could assist #ana"e#ent in ta)in" proper decisions. :o proper fi(ed asset re"isters

are )ept and inventor is not controlled at all. All these are #ulti #illion euro

assets.

The accounts for 21/2 have !een reconstructed over the past two #onths and

financial accounts have !een co#piled. Anne( 3 shows the 21/2 accounts and

hi"hli"hts fro# the #ana"e#ent letter showin" the deficiencies encountered.

+ollowin" is a snthesis of the o!servations,

!orporate "overnance

o :o effective control to #ana"e earl hospital operatin" costs

a#ountin" to 231#

Revenue

o :o strate"ic plans to sustain free health care services

o Revenue contracts not !illed to service clients

!reditors

o :o proper #ana"e#ent of earl contractual o!li"ations a#ountin" to

24#.

o $ossi!ilit of dou!le pa#ents to creditors

o :o control that a#ounts reuested confor# to co##it#ents

#harmaceutical and Medical $upplies

o :o proper stoc) control over phar#aceuticals and #edical supplies

o :o phsical stoc) ta)es carried out on phar#aceutical and #edical

supplies

o C(cessive hi"h value #edical supplies purchased ! consultants

o :o control over consu#ption of phar#aceuticals 5/#6 and #edical

supplies 521#6 leadin" to waste and out9of9stoc)E situations

#ayroll

o Fearl overti#e and allowances a#ount to 3@#

o Inefficient authoriation and no controls over pa#ent of overti#e

o Sa#e pa rates for on callE and on dutE services ! doctors

o :o proper cloc) in and outE of consultants& doctors and nurses

o ?nta)en Gacation eave and Ti#e 0ff allowances a#ount to 3.1@#

o :o #ana"e#ent control over paroll costs a#ountin" to /14#.

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%ngineering

o Identical spare parts purchased with different unit pricin"

o -ivil wor)s authoried not in line with approved tender specifications

o $a#ents effected to service providers e(ceed contract value

o :o e(penditure control in this sector 9 -urrent sste# leads to a!use

&i'ed Assets

o ?nauthoried transfers of hi"h value #edical euip#ent fro# one

location to another.

o :o proper securit to prevent theft of hi"h value euip#ent

o +inancial records disclose #edical euip#ent at //1# a"ainst

inventor records of ;@#

o :o effective control over purchases of fi(ed assets.

o +ree = !elow #ar)et leasin" of #edical euip#ent to private hospitals

and clinics

A costin" e(ercise of the activities at Mater Dei has !een re launched after it had

!een discontinued for no valid reason in 21/1. This should provide the !asis for cost

control of the processes at the hospital& as well as "ive a proper indication of the

char"es that should !e #ade to those who are not entitled to free hospital care at the

hospital.

The accountin" depart#ent is to !e totall reor"anised and retrained. $roper

accountin" policies& in accordance to international accountin" standards are to !e set

up& proper control sste#s are to !e put in place and ti#el& #eanin"ful #ana"e#ent

accounts are to !e #ade availa!le to #ana"e#ent to !e a!le to #ana"e the hospital

in a cost effective #anner& ensurin" that accounta!ilit is enforced.

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nfor8ation Technolo7:

The Infor#ation Technolo" at Mater Dei is in total disarra. There is no inte"rated

sste#& no holistic approach to a sste# solution& with the "overn#ent infrastructure

of MITA inhi!itin" a co#prehensive approach to sensi!le IT develop#ent throu"h

dictated policies& introvert attitudes& heav9handed !ureaucrac& o!sessive control&

and a one trac) approach in procure#ent.

This resulted in sste#s that are totall outdated& services that are o!viousl over

priced& total reliance on suppliers for the sli"htest service reuire#ent 9 !ein" at

their #erc even in accessin" patient data 9 a restricted nu#!er of suppliers& and an

inefficient sste# of develop#ent.

This is e(e#plified in,

A tender for the suppl of IT support to a nu#!er of operatin" sste# and which was

in the ad%udication process for #ore than 2 ears was a!orted. The price of around

24 #illion euros was !ein" uoted and the sste# was not considered to have !een

properl defined.

The Ministr was infor#ed in April 21/3 that the patient data!ase at the Health

Ministr& )nown as $AS will !e discontinued ! the end of the ear as it was such an

old sste# that it will no lon"er !e supported ! the supplier. This "ave little ti#e

to see) different sste#s and was presentin" the Ministr with the onl alternative to

roll over the contract with the sa#e supplier at a cost of around 2.4 #illion for a

new licence an up"rade and a #aintenance a"ree#ent for a te#porarE period of 4ears.

The review tea# i##ediatel started to redesi"n and pro"ra##e& in9house& a new

#odern sste# with increased functionalit. This is now !ein" finalised and should

!e i#ple#ented in ti#e ! the end of the ear. Su!stantial hurdles were placed in

the wa of the develop#ent tea# fro# various uarters& includin" the suppliers who

see# to have !een pro#ised a continuation of their contract. It is interestin" to note

that so#e das a"o the Ministr was infor#ed that the licence of the sste# would

not e(pire after all and onl the #aintenance a"ree#ent would need to !e renewed.

This new sste# will include new functionalit includin" the trac)in" of eachpatient at Accident and C#er"enc and at outpatient clinics& to set accepta!le

waitin" ti#es that would help the clinical practitioners to #ana"e patient flow&

ensure transparent ueuin" dependin" on tria"in"& and suppl #ana"e#ent with an

i#portant tool to assess and #onitor perfor#ance.

The e(istin" IT sste#s will !e reviewed to ensure a total inte"ration of all sste#s

within the Health Service& and new sste#s will !e developed to assist #ana"e#ent

and the clinicians to perfor# #ore efficientl.

In the process& we will also !e developin" in house IT capa!ilit so that we would

not have to rel on e(pensive consultancies and servicin" for the sli"htest

reuire#ent& and would ensure a fir# attitude to cost effectiveness.

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Human Resources

The #ost i#portant resources at the hospital are its hu#an resources. Althou"h we

!oast of the ualit of our hu#an resources& their deplo#ent is horrendous.

It is safe to state that the hospital is run on the whi#s and convenience of sin"le

e#ploees.

Data provided ! the Salaries section of MDH shows the followin",

$resentl at MDH there are '34different shift patterns 5e(cludin" the clinical staff6.

The shift patterns are distri!uted a#on" 3242staff& #ainl nurses

More than half of the shifts are assi"ned to a "roup of ten e#ploees or less while /@

shifts are wor)ed ! a "roup of 41 wor)ers or #ore. MDH has /43 staff that haveindividual shift

The shift patterns "enerate 22 different wor)in" hours=wee).

There are 1/4staff that are on reduced wor)in" hours. This "roup account

for 1*2shifts patterns.

There are #an wor)ers who have the sa#e duties !ut different shift patterns and

different shift pattern in different sections at MDH.

This #eans that the tas) of paroll calculation !eco#es a ver la!orious and tric)

tas) 521 e#ploees are reuired to calculate the paroll #anuall6& a lot of

disruptions are e(perienced in the flow of wor) and overti#e is "enerated to fill the

"aps created ! these distortions.

+or e(a#ple& it is a freuent occurrence that operations are not started on ti#e

!ecause the full tea# does not report to wor) at the sa#e ti#e& and the rest of the

tea# has to wait for the last #e#!er to appear. 'orst still& it also happens that

nurses chan"e durin" an operation !ecause of roster li#itations. Apart fro# "ross

inefficienc& this can also affect patient safet.

0ver the ears& laers of infle(i!ilit have !een overlaid one on top of the other with

the conseuence of lon"er process ti#es and wasteful hu#an resources. This is the

reason wh althou"h& as one can see fro# the Johns Hop)ins report& the staffin"

levels at the hospital are adeuate when co#pared with international !ench#ar)&

there is the insistence that we have a chronic shorta"e. Another issue is the

inordinate nu#!er of ualified clinical staff that have !een #oved out of their area

of co#petence to ad#inistrative duties. This #ust !e addressed throu"h an o!%ective

and thorou"h Hu#an Resource Assess#ent within an internationall accepted %o!

descriptions for each function and international wor) load !ench#ar)s

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Mana"e#ent has& over the ears& !een further wea)ened ! interference fro#

political #asters who dictated the appoint#ent of people without an consideration

of #eritocrac& forced staff #ove#ents not necessaril on an as needed !asis and

who pushed pet va"aries such as fa#il friendl #easures which& thou"h lauda!le in

the#selves& were ta)en to e(tre#es with the a!surd results of #riads of

un#ana"ea!le roasters.

The ?nions have filled the vacuu# created ! a wea) #ana"e#ent. There is the

culture of constant co#plaints ! a""rievedE #e#!ers that lead to constant

!ic)erin" !etween union and #ana"e#ent and the resultant waste of ti#e as there

as no set sste# on how "rievances should !e handled 9 and innu#era!le directives

which continue to clo" the wor) flow of the hospital and so#eti#e effect patient

safet. Apart fro# this& union leaders see# to thin) that the should !e runnin" the

hospital instead of #ana"e#ent.

It is i#portant that all those who wor) at the hospital realise that the wor) within

and for an or"anisation& and in the sa#e wa as happens all over Malta and the restof the world the #ust wor) within the para#eters set ! the or"anisation and

accordin" to the e(i"encies of service. Also& each e#ploee #ust utilise all his

capa!ilities in the !est interest of the patient.

Anne( shows the overti#e and allowances paid within Mater Dei hospital. The

practices are not accepta!le. There is no real accounta!ili t of who approves

overti#e and allowances& no indication that overti#e is wor)ed and allowances are

"ranted for a proper reason. 0verti#e is often an incentive used ! #ana"e#ent to

"et so#ethin" done. Massive savin"s can !e achieved in this area if #ana"e#ent

e(ercises proper control.

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n;entor:

Inventor& within this caption& refers to phar#aceutical and #edical supplies.

At the end of 21/2& Mater Dei carried 4.2 #illion in phar#aceutical and #edical

supplies inventor. This is a theoretical !oo) value as no stoc) ta)e has !een done

in Mater Dei as should !e the practice in a properl ad#inistered environ#ent.

Steps are !ein" ta)en now to start a continuous stoc) ta)e sste# which would "ive

a first cut indication of the accurac of the theoretical inventor shown on the

records.

Durin" 21/2& Mater Dei consu#ed 3 #illion in phar#aceutical and #edical

supplies. This consu#ption is #ade without even the !asic controls and in a free9for9

all environ#ent.

This #ust account for the waste of #illions of Curos in pilfera"e& outdated stoc)s&

and consu#ption of ite#s at hi"her prices then appropriate&

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Sste#s are not the onl issue here. $rocesses are also at fault. The are non e(istent

or not ro!ust enou"h with little or no concern for internal controls. However even the

pitiful ones in place are not enforced or used. Therefore the consu#ption of "oods is

#ade without even the !asic controls and in a free9for9all environ#ent. This #ust

account for the waste of #illion of euros in pilfera"e& outdated stoc)& and consu#ptionof ite#s at hi"her prices than appropriate.

This is clearl an area which has failed the pu!lic in a !i" wa in the past. This is an

area where #illions of euros have !een spent wastefull !ut it didnt have to. This is

one of the priorit issues !ein" tac)led at present.

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procedure is tanta#ount to a!ortin" an atte#pt to "et a !etter deal fro# the one that

was !ein" rolled over. :o tender would !e specified& issued& assessed& ad%udicated

and awarded in the four #onths re#ainin" until the e(piration of the current contract

period. However an effort has now !een #ade ! all concerned to issue a pu!lic

tender ! the end of 0cto!er.

This illustrates the deficient purchasin" process in other services contracts which

a#ount to a!out 23#illion in total 5Anne( 46

The procure#ent sste# to !e put in place will ascertain that an e(tensive cost

!enefit e(ercise will !e carried out on each service that is !ein" outsourced and

which will !e #ade well !efore the e(pir of an e(istin" contract to ensure that

effective options are availa!le to #ana"e#ent to ta)e the !est& #ost cost effective

decision. This will !e supple#ented ! an effective sste# to ensure continued

scrutin. This is another area where su!stantial savin"s can !e #ade.

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n;entor: in %os6ital

?sa"e in hospital wards is not properl trac)ed as there is no inventor control

sste# in place. Inventor in wards and in the operatin" theatres are not controlled

and the accessi!ilit to the stores area is open to all. This leads to shorta"es of so#e

ite#s in so#e areas were the sa#e ite# can !e carried in other areas. It leads tohaphaard orderin" as no consolidation of reuire#ents is done at an point in Mater

Dei. It also leads to waste as e(pir of ite#s is not properl #onitored.

As the new $AS sste# will ensure the identification of each patient throu"h a !ar9

code ta"& all the consu#a!les used wards& in theatre and in other interventions

should !e ta""ed and !arcoded so that.

There is proper recordin" of all that has !een used on a particular patient fro#

the ti#e of ad#ission to dischar"e. This ensures accurate records of

consu#ption and cost.

Inventor usa"e is properl controlled and accounted for& as it should reconcilewith was is phsicall reduced fro# the stores.

A visit to the stores in the sur"ical area is shoc)in". Access is open to everone&

there is no record whatsoever of the inventor carried& and there is no tracea!ilit of

an inventor #ove#ent. The !otto# line of this is e(cessive e(penditure due to

pilfera"e and waste.

In Mater Dei there is a co#plete lac) of !asic lo"istic= securit.

C(pensive supplies and euip#ent are NstoredN 5if ou can call it that6 in

unsecured roo#s with e(cess to ever!od even visitors.

There is no active i#plant and instru#ent inventor on the "eneral sur"erside at the #o#ent.

Instru#ent sterile collections are #ost of the ti#e unattended with outside

doors co##onl left open awaitin" for outside visitor to enter and "od )nows

what can happen.

:o!od too) the proper initiative to activate the card readers and create a first

level securit area.

+ro# now on it will !e # responsi!ilit.

In short& inventor control is non9e(istent.

This has its "enesis not onl in inefficient financial #ana"e#ent& !ut also in the fact

that there is no proper stoc) )eepin" function and sste# in Mater Dei.

Action is !ein" ta)en to,

Monitor and #aintain proper purchasin" activities and develop strate"ies and

new wor)in" practices which will eventuall save on costs.

Introduce the stoc) control and inventor pro"ra# throu"hout the whole

operatin" theatre co#ple( includin" anaesthesia and endoscop.

Activate the door #a"nets.

Appoint senior nurses to address specific sur"er specialit leadership whichwill include stoc) #onitorin" and predicted orders and top up needs. This will

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reduce traffic in our secured stores which will in turn reduce pro!a!le

pilferin".

*et the procure#ent officers in the operatin" theatre so that the will

understand the needs and "et hand on e(perience.

Appointin" the ri"ht people as product evaluators and eli#inate all potential

conflict of interests durin" the evaluation process.

support the new sste# of procurin" sur"ical euip#ent !ased on 3 reuisites ,

o Mar)et research of the product includin" retail price.

o C(pression of interest a#on" local suppliers at a pre9deter#ined price.

o $a per use sste# incorporatin" a clause to cover repairs and

replace#ent

It is also i#perative that an effective and efficient stoc) )eepin" sste# is put in

place to cater for,

An alert sste# for uantifin" reuire#ents to order

An orderin" sste# that reduces !ureaucrac and ensures a s#ooth deliverprocess.

A receivin" sste# that ensures that what is received is what is ordered and

that the ualit is accepta!le 5e.". the e(pir date has not !een chan"ed6.

An inventor control sste# that would )eep proper stoc) accountin"& ta)in"

care of all #ove#ents in and out of the different stores and !etween stores so

that #ana"e#ent at the Health Ministr and at the various entities would !e

a!le to have a view of the level of inventor of ever ite# at all stores

locations.

An IT sste# that would !e user friendl and efficient to #aintain such a

sste# without e(cessive effort. A phsical stoc) )eepin" function 5e.". a continuous stoc) ta)in" sste#6 that

would #onitor the correctness of the theoretical !alances stoc) )eepin"

sste#.

This has to !e set up fro# scratch.

&nhancin7 Cost &ffecti;eness in the S


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@11 each to /211. As there is no standard procedure& the sur"eon #a)es his

own choice as to which to use.

A #aintenance contract for repairs of so#e euip#ent was esta!lished at

2&411 each repair. 'hen this was uestioned& and a cost was reuested for a

particular repair euivalent to that contracted the cost was @41.

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Clinical )ractices

The level of care is hi"h& !ut it is disor"anised.

The throu"hput at the hospital and the cost is dependent on the presence of clinicians

on site& and a definitive state#ent of procedure that is strictl adhered to. This

depends on the function of a -linical Director for the hospital havin" the

responsi!ilit to set procedures& #annin" levels and !ench#ar)s for each clinical

activit. He should also !e responsi!le to #onitor the clinical activit and preside

over ualit assurance.

Mater Dei Hospital has e(tensive sur"ical capacit which is #anifestl underutilised

!ecause of wor)in" arran"e#ents that have !een handed down for# one collective

a"ree#ent to the other without anone havin" the sense and the coura"e to correct

the#. Cven thou"h a part ti#e=full ti#e #i( should !e #aintained it should !e #adeclear that the core clinical hu#an resource in the hospital #ust !e #ade up of

clinicians who are dedicated to the hospital& "ivin" their services solel to the

hospital on a full ti#e !asis.

This applies in particular to the -hair#an of each -linical Depart#ent who has to

have a#ple ti#e to deal with the ad#inistrative duties reuired of hi# while

#aintainin" his clinical output. It is also i#perative that -hair#en should !e "iven

ad#inistrative assistance to !e a!le to properl fulfil their ad#inistrative and control

function which could also include devolution of !ud"et responsi!ilit.

To encoura"e close colla!oration !etween the two #ain providers i.e. doctors andnurses& and to i#prove the wor)in" efficienc of !oth& one #a conte#plate creatin"

tea#s of doctors=nurses=para#edical staff to lead and wor) throu"h their wor)load

to"ether. Cach Depart#ent could have a nu#!er of such tea#s.

The Johns Hop)ins report deals e(tensivel with these issues in their o!servations

and reco##endations.

The sste# !ein" developed will !e !ased on the followin" para#eters.

Doctors in the health centres and private practice will !e "iven access to

patient clinical infor#ation as level of authorisation per#its& and would !ee(pected to deepen their level of dia"nosis& so that onl patients needin"

specialist attention will !e referred to Mater Dei out patient clinics and AOC

Referrals to Mater Dei will !e throu"h the "eneral practitioners and throu"h

doctors in health clinics. An IT sste# should !e installed in health clinics

and fa#il doctor clinics and will !e used ! the doctors to ensure that all the

dia"nostic steps are perfor#ed and all infor#ation a!out the patient is dul

co#pleted. This will !e connected in real ti#e to Mater Dei.

Cach patient reportin" at Mater Dei will !e i##ediatel ta""ed& "iven an

identification with !ar code& chip or #a"netic strip which will !e #onitored at

each step of the service "iven to hi# so that waitin" ti#es !etween one step

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Wa: For=ar>

The or"anisation and deliver of a patient centric ualit health care e(perience of

e(cellence is not& e(actl& a new paradi"# where success can onl !e reached

throu"h trial and error. There is no dou!t that the provision of health care is

challen"in",

the !alance !etween pu!lic financin" of health and rationin"

the provision of latest phar#aceuticals and dru"s and the i#pact on pu!lic

financin"

the provision of health treat#ent to patients at the ti#e when the need it so

that their health& and hence their role as parents& e#ploers or e#ploees&

"randparents does not de"enerate unnecessaril.

These and other challen"es !rin" in a level of co#ple(it that are not present in

other econo#ic and social sectors and which reuire special strate"ic& polic andor"anisational solutions.

Fet& "ood #odels of !est practice in the or"anisation and deliver of patient centric

ualit health care e(perience of e(cellence e(ist. 'ith stron"& deter#ined and

tenacious political and ad#inistrative leadership and the involve#ent of sta)eholders

the i#ple#entation of !est practice deliver of a patient centric ualit health care

e(perience of e(cellence ! Malta8s health service is realisa!le.

There are& however& cornerstone or"anisational and #ana"e#ent principles that

deter#ine the level of success realised. These are discussed hereunder.

Refocical Ser;ices

Despite the role of the central depart#ents within the Ministr of Health and the

centralised role assi"ned to the +oundation of Medical Services 5+MS6 the health

service hospitals& includin" MDH& operate independentl fro# one another&

replicatin" co##on services& applin" different processes and !ench#ar)s& etc.

In order to counter this wasteful fra"#entation it is !ein" reco##ended that the

hospital health services ar# of the health sector is desi"ned to replicate a privatesector #odel where co##on and shared services are lod"ed in a 7*roup8s holdin"

co#pan8 with the vertical service providers providin" a #ana"ed service deliver

throu"h clear service level a"ree#ents.

The report& therefore& reco##ends that the role of +MS is refocused fro# one that is

uasi co#pletel a facilities and pro%ect #ana"e#ent ar# to that of a *roup Holdin"

-o#pan providin" a Hospital 0versi"ht +unction operatin" under the supervision

of the Ministr of Health.

As a Hospital 0versi"ht +unction& +MS would !e assi"ned the followin"

responsi!ilities,

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ead a new cross9hospital "overnance structure to #onitor perfor#ance for

the provision of acute& reha!ilitation and outpatient patient centric ualit

service.

Be responsi!le for the develop#ent of a 7#ana"e#ent8 infrastructure within

+MS and the hospitals for which it is assi"ned responsi!ilit.

Be responsi!le for the develop#ent of co##on shared services infrastructure

within +MS and across the hospitals for which it is assi"ned responsi!ilit

whether these are I-T& financial& phar#aceutical #ana"e#ent& and other !ac)

office functions.

Develop centrall a"reed !ench#ar)s at !oth or"anisational level and

operational processes !ased on a $atient -harter directed to achieve a patient

centric ualit service provision.

$rovide oversi"ht& sharin" of !est practice and !ench#ar)in" across the acute&

reha!ilitation and outpatient health service value chain.

'or) with all participants to ensure that the are a 7!est9in9class8 patient

centric ualit service provider.

Achie;in7 ?"estinClass@ )atient Centric er

The refocusin" of +MS into a Hospital 0versi"ht +unction does not #ean that

hospitals will !e #ana"ed centrall. This is an approach that this report does not

su!scri!e to. The #ana"e#ent approach to hospitals will !e one that is !ased on

output and outco#e !ased plannin" fra#ewor) that would achieve the followin",

Ri"orous analsis of intended results cascaded down fro# #acro9level

i#pacts& such as increased e#plo#ent& to specific sector outco#es& such as

increased acute interventions. These results would !e clearl defined within

the respective hospital8s !usiness and financial plan& with indicators and

tar"ets& and with relevant #onitorin" and evaluation #easures. Additionall&

output and outco#e9!ased !ud"etin" would ensure that a hospital8s !usinessand financial plan !ud"et is for#ulated to deliver the results specified in

plannin".

in) to "enerational !ud"etin" in order to ensure that the outco#es and

outputs to !e achieved are ali"ned with the plannin" ti#e horion set within

the respective health sector polic "oals.

in) to the resources& structures& processes& etc. reuired to i#ple#ent the

polic o!%ectives with the effectiveness& efficienc& and econo# in

deliverin" the intended activities and services.

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Applin" sanctions where a!use is identified includin" the withdrawal of the

#ana"e#ent accounta!ilit provided under the ter#s of the perfor#ance

a"ree#ent.

A perfor#ance accounta!ilit fra#ewor) is a )e lin) of the oversi"ht #ana"e#ent

chain set with re"ard to the devolution of #ana"e#ent authorit to line #ana"e#ent.This is so !ecause a perfor#ance for accounta!ilit fra#ewor) entered into !etween

+MS and a hospital would provide& in tande# with the hospital8s !usiness and

financial plan& the #ana"e#ent accounta!ilit para#eters that the head of a hospital

is to operate within as well as the a"reed strate"ic and )e perfor#ance tar"ets the

incu#!ent is to #eet.

Moreover& the on9"oin" #onitorin" ! +MS ena!led ! this oversi"ht #ana"e#ent

fra#ewor) would allow it to intervene& and if necessar suspend the devolved

#ana"e#ent authorit& as and when necessar.

De;elo68ent of a ?(ana7e8ent@ nfrastr


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At the sa#e ti#e a Hospital Mana"e#ent -ourses=Trainin" $ro"ra##es are to

!e set up locall.

&;ol;in7 %os6ital Ser;ice Deli;er: into a %i7h al>e> !e= &cono8ic

Sector

The transfor#ation of Malta8s acute& reha!ilitation and outpatient services deliver

chain #ust !e driven ! the prero"ative of assurin" an econo#ic& efficient and

effective health sector that delivers a patient centric ualit health care e(perience of

e(cellence to the Maltese citien. :evertheless& this report underlines& stron"l& that

the vision for transfor#ation of Malta8s acute reha!ilitation and outpatient services

deliver chain should !e far !older.

The develop#ent of a new econo#ic sector !ased on hospital service deliver is one

of hi"h value added to Malta8s econo# and e(perience in overseas %urisdictions

shows that this is also intrinsicall lin)ed to 5health6 touris#.

Adoptin" an approach where Malta lin)s with a hospital of international repute with

re"ard to securin" assistance in the transfor#ation that needs to !e underta)en&

assistance in hi"h ualit hospital #ana"e#ent& and assistance in developin"

Maltese hu#an capital in hi"h ualit hospital #ana"e#ent would constitute a

se#inal step forward to the develop#ent of such a new econo#ic sector. If the wa

forward presented in this report is e#!raced& *overn#ent should tas) the Ministr

of Health and a newl re9focused +MS to wor) with sta)eholders to develop and

i#ple#ent the strate"ic inte"rated fra#ewor) that will successfull i"nite such a

sector si#ilarl to what has !een achieved in I-T and +inancial Services.

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Rethin9in7 Wellness The Fi78 chan7e

A"in" and technolo" are drivin" the future of healthcare deliver which has to !e

different fro# the sste# that we are usin" toda.

'e still have a healthcare deliver sste# in which phsicians see patients for /1921

#inutes and decide what to do !ased on what the doctor learned in #edical school orpic)ed up throu"h continuin" #edical education. 'e still have hospitals and nursin"

ho#es and phsicians offices or"anied in #uch the sa#e wa the were 41 ears a"o.

True& there are lots of new technolo"ies that allow hospital stas to !e shorter and to

turn patients livin" roo#s into I-?s& !ut the institutions reall haven8t chan"ed #uch.

'ill the co#!ination of new science on the one hand and a"in"& de#andin"

consu#ers on the other !e si#pl !olted on to the current chassis of healthcare

financin" and deliverL Most healthcare e(perts !elieve this does not co#pute. 'e

desperatel need to innovate.

the "reatest innovation #ust co#e in the deliver of #edical care. Healthcare needs to !eredesi"ned to full ta)e advanta"e of advances in infor#ation technolo". The #edicine of

the future needs to !e hi"h tech and hi"h touch& it needs to co#!ine the potential efficienc of

e9co##erce with co#passion and carin" fro# #otivated professionals.

nno;ation

(nnovation has quic)ly come to be one of the top issues that senior healthcare e'ecutives and

medical professionals are thin)ing about.

There is a realiation that there is an ur"ent need to challen"e the ver philosophies upon

which the sste# is !uilt. The result is that #an health care leaders are see)in" insi"ht into

/C(cerpts fro# contri!utions fro# the followin" we! sites,

Three Arup Specialists Share Their Gision of The +uture of Healthcare Desi"n 9

htt655===.arch>ail:.co8543//5

oo)in" Ahead, A +uturists Giew of Healthcare Ian Morris 9 http,==ian#orrison.co#=loo)in"9

ahead9a9futurists9view9of9healthcare=

Healthcare 2111 The transfor#ative trends that will reall define our future Ji# -arroll 9

http,==www.%i#carroll.co#=21/1=/1=healthcare921219the9transfor#ative9trends9that9will9reall9

define9our9future=P.?#o?Ql#i#

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the #a%or scientific& technolo"ical& consu#er and social trends that will allow for so#e ver

dra#atic chan"e in the concept of health care deliver. $reventative concepts are part of this

!i" transition.

'ithin a decade& health sste#s would have successfull transitioned fro# one which fi(espeople after the8re sic)E to one of preventative& dia"nostic "eno#ic9!ased #edicine that

treats patients for the conditions we )now the are li)el to develop. Innovation is no lon"er

%ust a fashiona!le phrase with the co#in" chan"es& innovation is the critical new leadership

focus for e(ecutives in the health care sector.

'hat is happenin" is this, we are in the #idst of a lon" ter# trend in which preventative

#edical careE will co#e to e(ceed what we spend on reactive #edical care.E $reventative

care ta)es #an for#s& fro# "enetic testin" 5to deter#ine what conditions people are li)el

to develop in their lifeti#e6 to wellness and other preventative pro"ra#s. Si#pl put& let8s fi(

people !efore the are sic)& rather than treatin" the# after the8ve developed a condition.

In the future& an effective Health Deliver sste# will !e,

)re;entati;e'ithin the ne(t decade& if we do the ri"ht thin"s& we will have

successfull transitioned the sste# fro# one which fi(es people after the8re sic)E

to one of preventative& dia"nostic "eno#ic9!ased #edicine. Treatin" patients for the

conditions we )now the are li)el to develop& and re9architectin" the sste# around

that realit.

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appoint#ents with doctors thousands of #iles awa& the future holds enor#ous potential for

i#provin" lon"evit and ualit of life for people around the world.

Such innovation will reuire real leadership fro# polic#a)ers& entrepreneurs& and

phsicians ali)e. The sta)es are hi"h. If we don8t innovate it could "et u"l.

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A S8art Sol


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A %ealth Ser;ices &cono8ic Sector

Malta has the ele#ents that can propel it into a hu! of Medical Services in the Mediterranean

Re"ion and !eond.

An or"anised& well #ana"ed& efficient& patient centric hospital sste# can attract patients

fro# countries where ualit is inferior to ours 5e.". i!a6 and fro# countries where costs

are #uch hi"her to ours 5e.". ?SA6

This will,

Be a contri!utor to the Maltese Ccono#&

+unds the local health sste# to i#prove sustaina!ilit

-reate #ore e#plo#ent&

$resent an opportunit to our professional classes to i#prove their inco#e&

*ive a !roader !ase for invest#ent in hi"her technolo" in the #edical sector

Increase the scope of $rivate 0perators in the Medical Sector&

I#prove the service "iven to the local population.

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Annex 1

(ater Dei %os6ital

S:ste8s Re;ie= B !ee>s Assess8ent

J O % ! S % O ) - ! S ( & D C ! & ! T & R ! A T O ! A #

Final Re6ort &ec


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+,,-0 C**+/0 B//;E-,+/3- CBE ,+-33

T?- *


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Reallocate current space to allow for additional AOC treat#ent spaces inpatients

should !e relocated outside of the AOC.

Review the inpatient ad#ission process& includin" decision #a)in" points and rin"

fenced !eds.

?tilie !est practice for inpatient !ed #ana"e#ent includin" central !ed control and

esta!lish a priorit for patients ad#itted throu"h the AOC.

Review and revise current AOC tria"e process and revise the Nfront endN AOC

operations to #atch patient de#and.

Develop evidence9!ased clinical practice "uidelines and care protocols.

Review the slow and erratic inpatient dischar"e process& focusin" on non9acute&

Nlon"9staN patients and the real !ottlenec) outside of the Mater Dei Hospital

$atients held in corridors represents a serious safet ris)

Assess elderl care and reha!ilitation capacit !uildin" options outside of Mater

Dei Hospital

8. %erioperative Services 0Surgical -ait )ists

Csta!lish standards and rules as part of an advanced schedulin" and #onitorin"

sste#.

C#power operations #ana"ers to i#prove utiliation and throu"hput.

Re9evaluate nurse staffin" needs in operatin" roo#s 50R6 and esta!lish

ad#inistrative sste# to support 0R procure#ent& suppl& inventor& case

preparation #ana"e#ent.

Develop sste# to #easure cost per sur"ical case.

Incentivie sur"eons to wor) #ore hours and fill entire 0R capacit.

O6tions (o;in7 For=ar>

&arl: Achie;e8ents

So#e specific reco##endations have alread !een i#ple#ented ! the e(ecutive

leadership with positive effects,

C#ploed -00 and Medical Director

Identified 0perational 0!%ectives for 21/2

Appointed a nurse as 0R Mana"er

Redefined the hospitals Mission State#ent

Set up a Sste#s Review Board to loo) at patient safet issues

Defined an 0perations $lan for :ursin" Started coordination with BioMalta

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Be"un definin" AOC protocols

)rere


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3. Train selected phsicians and nurse leaders

. $rovide on9"oin" consultin" support to hospital leadership in strate"ic areas

ualit assurance and patient safet sste#s

Bed #ana"e#ent Inte"ration of infor#ation sste#s Joint -o##ission International

accreditation

Re +o;ern8ent S


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*ave the relevant parts of the report to the nursin"& doctor and allied

care professionals #ana"e#ent tea#s for their i#ple#entation where possi!le

Received "ood feed!ac) fro# nursin" tea# !ut ne"li"i!le feed!ac)

fro# doctors or allied professions 2 all wor) done ! nursin" on the report is

docu#ented Started the concept of patient safet& reor"anised incident reportin"

sste#& launched a dedicated tea# for ualit and Safet for the whole

hospital that is currentl focusin" on The ri"ht Bed for the Ri"ht $atient 9

leadin" to safe and ualit care.

As)ed to have a full ti#e person focusin" on the detailed

i#ple#entation of tas)s 5ii6 and 5iii6 and approval received fro# $er# Sec to

appoint Dr. enneth *rech on the tas) i#ple#entation.

Tas9 Ei; Assess the nte7ration of T s:ste8s

V Csta!lished what we )new alread that MDH has no authorit for anIT activit as it is all controlled ! MITA and the Ministr for Health.

This part of the report sas #ore a!out what should !e done than a!out

what we have as we have ver little so far fro# an MDH position.

Tas9 E; &;al

(ater Dei hos6ital to a>;ance clinical an> research collaboration

:o wor) was done on this for# and MDH standpoint

Tas9 E;i Assess the cs assess8ent of

the acci>ent an> e8er7enc: EAB& >e6art8ent

Csta!lished that the Area allocated for AOC is s#all currentl in the

process of to creatin" space in the ad#ission areas to "ive AOC #ore

area where to see their patients

-linical protocols are now put in and perfor#ance #easures and tar"etsesta!lished a"ainst which we can !ench#ar)+

Tas9 E;iii Con>


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V Review spea)s a!out how practices can !e #ore efficient& na#el in the#ana"e#ent of the theatres& the shifts of nurses to !e #ore effective and theIT support to #onitor perfor#ance

o I as)ed for a theatre director in Jul 21// !ut this one has not !een appointed eto :urses shif ts will need a tussle with the union to ta)e up and this was not seen as

the ri"ht thin" to do%ust !efore the elections when I raised the issue over a ear and a half a"o o MITA and

our own Ministr D* IT stopped #e fro# outsourcin" to an local co#petent supplier

the writin" of software for #e to #ana"e theatre efficienc !etter.

The JHI report instilled the notion and discussion and focus on all aspects of $atientSafet& which I a# told& previous to this JHI visit& was not considered at an widescale in the hospital.

Jose6h Car


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Annex 3

(ater Dei %os6ital Finance De6art8ent

Obser;ations an> Reco88en>ations

A detailed report of this C(ecutive Su##ar has alread !een presented and discussed with the Minister ofHealth,

3


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(AT&R D& %OS)TA# 2

State#ent of -o#prehensive Inco#e +or the ear ended 3/ Dece#!er 21/2

2012 21//

Re;en&/@;&@/&12>&1426

!et O6eratin7 Costs E20,12',43 5/&3@&;3&2@>6

4


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(AT&R D& %OS)TA# Annex 2

$aroll Su##ar ! -ost -entre

Cost Centres "asic Allo=ances O;erti8e De>2;&32 2&3>;& @&32&1@/ /&//@ 2@1&32 2&2 &2@> /&4>&;2/ //4&>12 /&4@4&423

K 100 23 0 0 123 10 132

M ed ic al I #a "i n" 3 &4 &1; / 1; &< /2 2 @&24 ; 4 & 43 & @4 />&2@> / &2>1 2; 21&&


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Cost Centres "asic Allo=ances O;erti8e De>> /4 /& 241 /1& @3 3;&;1; &4@/ /&/22& @< /1 &2 2@& 13/ &@;@ /3@ &>;2 2&1;> &@31

K 100 42 2 14/ 11 1'/

Cn"ineerin" /&1


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(AT&R D& %OS)TA# Annex 6

21/2 -ontractual 0!li"ations

)ai> Contract

Contractor Details al3&;1 >2&@ < 3&411&111 22&@>

john dalli - report on mater dei for pm

Documents