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Tallaght tries to turn the corner
[ by Niall Hunter, Editor www.irishhealth.com]
Back in August, Eilish Hardiman took up what many would regard as one of the most unenviable jobs in the health service - running the beleaguered Tallaght Hospital in Dublin - to many people, a by-word for health service dysfunctionality.
She is the hospital's sixth chief executive in 13 years.
Eilish Hardiman came to Tallaght from another challenging role, as chief executive of the National Paediatric Hospital Development Board. A qualified nurse, she was formerly a deputy CEO and Director of Nursing at Dublin's St James's Hospital.
On arriving at the 625-bed south-west Dublin hospital, Ms Hardiman was faced with a number of challenges- ongoing problems with ED overcrowding, a data protection breach, the continuing fallout from the x-ray scandal of last year, major financial issues, and a need to fast-track reform of how the hospital was run and managed.
In an interview with irishhealth.com, Eilish Hardiman says she believes Tallaght is turning the corner and faces a brighter future.
She says despite its problems, she always knew Tallaght had excellent staff and had huge potential. "It just needed to become more operationally efficient and financially more robust and then decide where its future lay within the healthcare system. We are one of the ‘big five' hospitals in Dublin and have a lot to offer."
Changing the hospital's board
Tallaght was not reforming itself quickly enough for Health Minister James Reilly, who last month stepped in to change the charter of the hospital and restructure the Tallaght board.
As the hospital's financial crisis worsened, the Minister apparently believed Tallaght had not taken effective enough action to change its governance in the wake of last year's x-ray and referral letter scandal.
This was in spite of two major reports, including the Hayes report on the x-ray scandal recommending that these changes should be made.
And more than a year after the x-ray scandal broke, the safety body HIQA in early summer cited governance problems in announcing its review of the safety of Tallaght's A&E department. So why has it taken so long to change things?
Says Eilish Hardiman: "I believe the board has in fact for the past 18 months been actively reviewing its governance, post-Hayes. Because Tallaght's charter is the legal framework, you have to work within that and the current charter prescribes how the board should function."
"The previous board had put a transition board in place last year with the intention of effecting bye-laws to change the board to one of the size and type recommended by the reports. That didn't come to fruition but it was agreed to reduce the membership of the new board. Changes were made - they reduced the board from 23 to 14 In July and brought in skillsets such as legal, financial and business onto it".
Asked why the hospital board appointed in July was not in line with previous recommendations that it should only have 10-12 members, Ms Hardiman said she only began at Tallaght in August, she had not been a party to what happened before.
She stressed, however that the outgoing hospital board, which is set to be replaced by a new nine-member board of which the Minister will have effective control over most of the appointments to it, was modernising and restructuring as much as it could within the confines of its current charter.
"The Minister himself has acknowledged that the board had indeed changed and moved on. He needed further changes. The board, to give them their due, have been very positive and have accepted that change."
Eilish Hardiman does not accept that the State is effectively taking complete control of Tallaght, and stresses that the hospital's voluntary status is being maintained.
She says the board changes need to be taken in the context of what the future structures of hospitals will be under reforms planned in the health system. This will involve hospitals operating as trusts under a good deal of local autonomy.
Why did the scandals happen?
While obviously Eilish Hardiman was not working in Tallaght when the recent controversies took place, does she have any take on why these scandals developed?
"Some of the issues go back to 2009 and before, and to be fair, things did start to improve in 2010 and 2011. From my perspective, the delayed x-rays issue was not unique to Tallaght, but you do need to have structures in place that are very clear on where there is responsibility, authority and accountability. Each member of staff in charge of a particular area needs to know the standards they must work to."
Ms Hardiman says a key feature of the change process is getting doctors involved more in management through clinical directorates. She says this had started at Tallaght in recent years but needs to be developed further.
She believes staff are very positive about the need to change the way the hospital goes about its business.
Admitting that perhaps there had been some '‘ringfenced' approaches in place as regards how the hospital was run since its foundation in the late 1990s, she says the necessary changes are now being made.
Morale
Was morale low was low at the hospital when she took over in August?
"Well, people who are working hard here do find it a knock when there is negative publicity about the hospital."
"However, one of the most heartening pieces of information I received early on when I came here was a staff survey done last year in which 78% of staff said they wanted change and were willing to facilitate change. So you have a cohort of staff that knows they do need to change how they operate, but they obviously needed direction and a plan of how that should take place."
Post-scandal changes
But as Tallaght tries to reform its structures and systems, Eilish Hardiman admits it is disappointing that some key recommendations of the Hayes report into the x-ray scandal have not been fully implemented.
"We are still working on some of the radiology staffing issues. While we got two additional radiologists, as recommended in Hayes, two radiologists have since retired so the net effect hasn't been any better."
She said the replacement of one of the retired radiologists is in progress and the other replacement post is not approved as yet.
Also, more than a year after Hayes recommended it, Tallaght is still trying to get approval from the HSE to upgrade its IT to make it work more efficiently. "We still need a voice recognition system to avoid staff having type up x-ray reports."
"That is clearly disappointing, but we are meeting with the HSE shortly to try to address any outstanding issues with the Hayes recommendations."
Ms Hardiman said getting the additional radiology staff, upgrading CT equipment that needs to be replaced and an expected move to an 8am to 8pm core working day for radiology from January, will improve the operation of radiology at the hospital and help cut waiting lists for diagnostic tests.
She says the hospital is currently recruiting a director of quality and safety and a director of operations- appointments which were recommended in the wake of the x-ray scandal.
ED problems
Since Eilish Hardiman took over at Tallaght just over three months ago, there has so far been a notable reduction in the number of patients waiting on trolleys in its ED.
There was a grim legacy here - trolley number reaching 40 plus on some days and HIQA back in June launching a probe into Tallaght's ED following critical remarks by the County Coroner in relation to the death of a patient in a corridor.
Ms Hardiman said trolley numbers have been reduced through a number of initiatives in recent months.
"There were beds on the corridor and patients were being nursed on the corridor. We moved the patients and the nurses to a reopened ward and this was done at no extra cost. We started reorganising to ensure discharge planning, admissions and bed management were all coordinated.
"We re-assigned discharge planners to ward areas so they knew what was happening in particular wards. We worked very hard with Peamount Hospital on improving the provision of step-down beds there in order to free up our acute beds. We managed to reduce the length of stay of medical patients by point six of a day in nine weeks."
She says at this stage, following the organisational improvements, the hospital no longer needs the reopened ward for ED overflow. "Patients are now on wards rather than in the overflow ward. More recently, the Minister for Health's new Special Delivery Unit has given us additional funding which has allowed us to move the longer-term care patients out of ward areas into what was previously the overflow ward."
Currently, the hospital admits 30% of its emergency department attendees - it aims to reduce this to 24% by providing alternative care models.
Tallaght is also shortly to get an additional emergency medicine consultant. Eilish Hardiman believes these recent improvements in ED performance will stick.
New care pathways
The new CEO says Tallaght is aiming to reduce the length of inpatient stay by offering more efficient and less costly alternative modes of care, or ‘admission avoidance' strategies.
This will include introducing a medical assessment unit this month and a medical admissions unit in January. "There will be rapid access clinics where patients will be brought into the clinic and treated by the consultant by the next day and treated then as an outpatient as opposed to an inpatient. People with mild chest pain will be seen by a rapid access care team."
She says the above initiatives will help reduce inpatient admissions by 1,500 next year and will reduce the demand on beds.
As with many hospitals, Tallaght has problems with patients who have finished their acute treatment, but due to the lack of alternative community or long-term care, remain in hospital beds. These 'delayed discharge' patients over two wards at present and this obviously affects bed availability at any given time.
Eilish Hardiman says in order to tackle this long-running problem, the Fair Deal scheme for nursing home supports needs to work better in terms of access to longer term care, the availability of home care packages also needs to be looked at to avoid frail elderly patients having to remain in acute hospitals and becoming more dependent, and the provision of intermediate care beds also needs to be addressed.
Recent controversies
She says the recent legal issue between Tallaght and HIQA over HIQA's ED investigation process has now been settled. "We met with HIQA and discussed the issues and managed to resolve them."
The HIQA propbe on the safety of Tallaght's emergency department services is expected to report shortly.
Another recent controversy at Tallaght was the reported patient confidentiality breach relating to the transcribing of doctor's notes on patients by a firm in the Philippines to which the hospital outsourced the transcription service.
She says this is still being investigated in the Philippines and bythe Data Protection Commissioner. She says the new arrangements on patient report transcribing, following the hiring of a new firm to do this, are in line with data protection requirements.
Financial problems
Tallaght Hospital is among those with the biggest budget deficits at present - around €11 million. It will be carrying this deficit over into next year. As this may simply be added to a potential further deficit next year, is this going to adversely affect services?
"It will be a challenge. For the past two months we have not overrun our budget, so we are not adding to the deficit. We are implementing operational efficiencies - reducing admissions by 1,500 and reducing the demand on A&E by providing alternative care pathways, reducing the length of stay, increasing day surgery, greater provision of step-down beds etc. We do plan to close a 30-bed ward in the new year - this is an operational measure rather than a cutback- if we are being more efficient in our operations we will not need the ward. If you close a ward you reduce your requirements on bank, overtime, agency staff etc. We will be treating the same amount of patients but we will be treating them differently."
Eilish Hardiman says another savings measures Tallaght will implement shortly is to halt the majority of referrals that are from outside the hospital's catchment area.
"Between 10% and 12% of referrals to us are from outside the Dublin-mid -Leinster region. I was talking to the local office in the HSE Dublin-North-East today and said ‘sorry, these patients are inappropriate referrals for Tallaght, and need to go to one of the Dublin hospitals in that catchment area.' We are not funded for patients outside our catchment area - there are hospitals on Dublin's northside that are funded to do so."
She stresses that this referral ban would not include 'high-tech' national specialty referrals which Tallaght caters for from outside its catchment area, but the restruction would largely take in lower-grade 'secondary' care, which can be carried out by other hospitals locally.
"There is no need for these patients to be coming to Tallaght Hospital."
Waiting lists
Eilish Hardiman says Tallaght should be on target to meet the deadline set by Health Minister James Reilly of no hospital having anyone waiting for planned inpatient treatment for longer than 12 months by the end of the year.
"We are working hard to ensure this happens and we are aiming to have the maximum wait down to nine months by the end of next year."
She doesn't necessarily believe that concentrating resources on cutting the number of long waiters will lead to a bottleneck at the lower end of the waiting lists and in time, an overall increase in lists. There is evidence that this is already taking place, and there are concerns that the NTPF no longer routinely deals with those patients over three months.
"It's regarded as good operational practice that you move from the back of the list and make sure there is nobody waiting for a very long time. It requires management focus to get the lists down and good cooperation with surgeons and anaesthetists. Sometimes, long waiters may have been offered treatment but have not accepted it. You need to ‘clean up' lists to make sure they are contemporary."
The future
Part of Tallaght's future will be getting a maternity hospital on site - this will result from the Coombe hospital moving there.
This is regarded as a boost for Tallaght, which is set to lose its children's hospital when it moves to the Mater site, and has already missed out on being designated one of the country's eight major cancer centres.
While this development may still be a long way off given the state of the economy, Eilish Hardiman says Tallaght will be submitting a business case to the HSE for the maternity unit before Christmas, and it will be a private-public partnership project.
Eilish Hardiman says she believes Tallaght Hospital, after all the controversy, is now turning the corner.
She says key factors in this process have been improving the ED situation, restructuring bed management, moving from outdated models of patient care, and implementing management and governance restructuring. Consultant clinical directors have been put onto the executive management team. "There is now much greater clarity around who is responsible for what."
"Some of these reforms had already started before I arrived in August and some have started afterwards."
Asked it the basic problem with health service failures of recent years is that ‘systems', rather than people, are always blamed so nobody steps up to the plate, she does not feel it's as simple as that.
"If you don't have a clear structure in place then it is a bit of ‘everybody, somebody, nobody and anybody' in terms of who is responsible. It is critical for high performance hospitals to have a clear structure of where responsibility, authority and accountability lies. You have to ensure you have the capacities and capabilities in key management posts to deliver on those responsiblities."
Anonymous Posted:
14/12/2011 12:10 |
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"Dsicharge planners" this surely used to come under the functon of ward sister? Seems like a case of more staff being paid to do less work. |
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