Don Hindle

Does restructuring hospitals result in greater efficiency - an empirical test using diachronic data

Hospitals are being restructured more frequently. Increased cost efficiency is the usual justification given for such changes. All 20 major teaching hospitals in Australias two most populous states were investigated by classifying each over a 5-6 year period in terms of their cost efficiency (average cost per case weighted by Australian diagnosis-related group [AN-DRG] data and adjusted for inflation) and structure, categorized as traditional-professional (TP), clinical-divisional (CD), or clinical-institute (CI). In all, 12 hospitals changed structure during the study period. There was slight evidence that CD structures were more efficient than TP structures but this was not supported by other evidence. There were no significant differences in efficiency in the first or second years following changes from either TP to CD or TP to CI structures. All four hospitals changing from CD to CI structure became significantly less efficient. This may be due to frequency rather than type of change as they were the only hospitals that implemented two structural changes. Hospitals that changed or did not change structure were similar in efficiency at the beginning and at the end of the study period, in overall efficiency during the period, and in trends toward efficiency over time. The findings challenge those who advocate restructuring hospitals on the grounds of improving cost efficiency.

How important are quality and safety for clinician managers? Evidence from triangulated studies

Aims to discover the work hospital clinician managers think they do and observe them in practice. A total of 14 managerial interests and concerns were identified in focus group discussions. Clinician managers’ jobs are pressurised, and are more about negotiation and persuasion than command and control. Their work is of considerable complexity, pace and responsibility and it is predicated more on managing inputs (e.g. money and people) than care processes, systems, outputs and outcomes. Thus the capacity of clinicians in these roles to respond to reforms such as those envisaged in the Bristol Inquiry may be problematic. Qualitative studies are re‐affirmed as important in providing grounded insights into not only clinical activities, but also organisational behaviour and processes.

Casemix-based funding of Northern Territory public hospitals: adjusting for severity and socio-economic variations

The Northern Territory intends to make use of Australian National Diagnosis Related Groups (DRGs) and their cost relativities as the basis for the allocation of budgets among public hospitals. The study reported here attempted to assess the extent to which there are variations in severity of illness and socio-economic status which are not adequately explained by DRG alone and, if so, to develop a DRG payment adjustment index by use of routinely available data items. The investigation was undertaken by use of a database containing all discharges between July 1992 and June 1995. Hospital length of stay was used as a proxy for cost. Multivariate analysis was undertaken and it was found that several variables were associated with cost variations within DRGs. Stepwise multiple linear regression was used to develop a model in which 14 variables were able to explain 45% of the variations. Index values were subsequently computed from the regression model for each of eight categories of admitted patient episodes which are the intersections of three binary variables: Aborigine or non-Aborigine, rural or urban usual place of residence of the patient and hospital type (teaching or other). It is intended that these index values will be used to compute differential funding rates for each hospital in the Territory.

Linking measures of health gain to explicit priority setting by an Area Health Service in Australia

A demonstration project was undertaken to develop an integer programming model that could help a regional health authority to take into account data on service effectiveness when allocating resources to acute inpatient services. The model was designed to find the mix of services that would maximise health gain from the available resources, and so provide information that could be used to encourage hospitals to change their patient mix. It was developed in collaboration with an Area Health Service in New South Wales, Australia, with the aim of assessing its potential as a decision support tool. Acute inpatient services were categorised in the model using classes derived from the Australian National Diagnosis Related Groups (AN-DRG) classification and the classes developed by the Oregon Health Services Commission. Estimates for the effectiveness of each service was derived from the Oregon benefit data. Estimates of resource use were derived from AN-DRG data. The expected demand for each service was derived from local activity data. Various scenarios were developed to assess the potential of the model to support decision makers. These mimicked plausible policy options and tested the sensitivity of the results to changes in the data. The scenarios demonstrated the model could reveal the consequences of different policy options, but also suggested that the difference in the cost-effectiveness of services close to the margin would be small and so a rigid approach to priority setting is undesirable. Difficulties in developing the model also demonstrate that incorporating health gain data into resource allocation decisions will not be straight-forward for health planners.

Hospital Sector Organisational Restructuring: Evidence of Its Futility

Restructuring is a prevalent managerial strategy, favoured by those who say they seek to create improvements by merging organisations, streamlining organisational hierarchies or rationalising reporting arrangements (Brocklehurst 2001; Lathrop 1993; Relman 2005; Sen 2003). Proponents tend to argue that they will create through their restructuring efforts greater efficiency, i.e. more benefit for the same or less cost. Restructuring is typically sponsored by those in political or executive positions with capacities to enact such change and assume responsibility for leading efficient and effective services.

Using simulation to educate hospital staff about casemix

When the Australian government funded a casemix development program, few hospital clinicians or staff knew much about casemix classifications like Diagnosis Related Groups (DRGs). Although the concepts behind casemix are essentially simple, it is not a trivial task to explain the logic used to assign patients to classes, or the use of casemix data for management or funding. Therefore, as part of a project to create educational material, a computer‐based management game, built around a simulation model of a hospital, was developed.The game was designed for use in a workshop setting, to allow participants to test their understanding of the casemix information presented to them. The simulation mimicked the operation of a hospital, with a player taking the role of a hospital manager. It aimed to demonstrate how AN‐DRGs might be used for funding; how patient costs are influenced by hospital activity; and how casemix data can assist in monitoring the use of resources.The game, called Dragon, proved to be very successful, and is now distributed as part of the National Casemix Education series.

What do health professionals think about patient safety

IntroductionPatient safety is a main determinant of the quality of healthcare services. The literature shows that the occurrence of medical errors is quite important in countries where it has been measured. Various actions like legislative measures, financial, or educational measures may help, but they are not always effective in controlling the level of avoidable errors. That happens because patient safety is strongly related to the culture specific to healthcare organizations. This study is aimed at getting some perspective on the organizational culture in Romanian hospitals in regard to patient safety.ObjectivesThe main objectives are (1) to identify the views of healthcare professionals about patient safety in Romanian hospitals and compare them with other countries, (2) to identify to which extent the views about patient safety relate to the specific organizational culture in healthcare, and (3) find out if there are differences in perceptions of professional categories about their own work and that of the clinical team.MethodA survey was conducted, based on a questionnaire. The questionnaire was aimed at realizing a screening of the problem, to get some specific views of respondents from their work experience, and eventually to get suggestions on how to improve patient safety. The same questionnaire has been previously applied in four other countries: Australia, Singapore, Sweden and Norway. Overall views of hospital professionals from Romania were compared to those from the other countries. Also, views per professional categories—clinical vs. non-clinical staff, doctors vs. nurses, and senior vs. junior staff—were compared.ResultsAnswers from 100 respondents from Romania indicate that patient safety is a major concern of hospital professionals, and it should be improved. Basically, they show as much interest and willingness to improve as observed in the other countries. This indicates that no major differences in the organizational culture exist in regard to patient safety. However, differences among professional categories have been noticed; for example, nurses are more aware than doctors on the need to take action for improving patient safety.ConclusionsPatient safety is a major concern of health policy in many countries. In Romania, this study shows concern of professionals about patient safety, although they are facing many barriers such as inadequate leadership, lack of communication between professional categories, between senior and junior staff, and most of all with the patients. This is a problem of organizational culture, which requires complex, multi-level strategies, targeting a long-term change. Results of this initial study should be viewed as a baseline for a larger study.