Towards Outstanding Care at the Royal Hobart Hospital

External Consultation for ED Advisory Panel (EDAP) – A Review of Patient Access at Royal Hobart Hospital

5 August 2019

Professor Harvey Newnham MBBS, FRACP, PhD, GAICD

Associate Professor David Hillis MBBS(Hons), MHA, DEd, FRACGP, FRACMA, FRACS(Hon), FCHSE, FAICD

Towards Outstanding Care at RHH – Newnham/Hillis

TABLE OF CONTENTS EXECUTIVE SUMMARY ...... 3 PREFACE ...... 7 REPORT FINDINGS ...... 8 1. System and Organisational Enablers ...... 8 Background and “re-thinking the vision” ...... 8 RECOMMENDATION 1.1 ...... 9 Lack of Clarity in Governance ...... 9 RECOMMENDATION 1.2 ...... 10 RECOMMENDATION 1.3 ...... 12 Engagement and Empowerment of staff / clinicians ...... 12 RECOMMENDATION 1.4 ...... 14 RECOMMENDATION 1.5 ...... 15 Culture ...... 15 RECOMMENDATION 1.6 ...... 16 Change necessity ...... 16 RECOMMENDATION 1.7 ...... 18 Improve the voice of the consumer ...... 18 RECOMMENDATION 1.8 ...... 19 Data / Information / IT ...... 19 RECOMMENDATION 1.9 ...... 20 RECOMMENDATION 1.10 ...... 21 2. Understanding patient flow, access block and risk sharing...... 22 Patient Flow ...... 22 Sharing of Risk ...... 23 RECOMMENDATION 2.1 ...... 24 What happens when the ‘system” is under serious access stress? ...... 25 Why are risk and urgency not equally shared across the system? ...... 26 3. Improving flow to improve patient access ...... 27 Non-admitted patients attending the ED ...... 28 Reducing patient presentations to RHH ED ...... 28 Community-based alternatives to ED attendance or patient admission ...... 28 RECOMMENDATION 3.1 ...... 30 Ambulance assessment, treatment and transport ...... 30 RECOMMENDATION 3.2 ...... 31 Relationships with other hospitals ...... 31 RECOMMENDATION 3.3 ...... 32

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Ambulatory care clinics ...... 32 RECOMMENDATION 3.4 ...... 32 Improving the progression of care for “non-admitted” patients in the ED ...... 32 RECOMMENDATION 3.5 ...... 34 Improving access and flow for Admitted patients ...... 34 Patients admitted to the EMU (Emergency Medical Unit) ...... 34 RECOMMENDATION 3.6 ...... 35 Patients admitted to and discharged directly from the acute ward...... 35 RECOMMENDATION 3.7 ...... 36 RECOMMENDATION 3.8 ...... 39 Patients admitted to the ward who require inpatient subacute care, rehabilitation or limited community-based services...... 39 RECOMMENDATION 3.9 ...... 41 Intensive Care Unit at RHH (ICU) ...... 41 RECOMMENDATION 3.10 ...... 42 General Medicine as a case study ...... 42 RECOMMENDATION 3.11 ...... 44 Surgical and Perioperative Services at Royal Hobart Hospital ...... 44 RECOMMENDATION 3.12 ...... 46 Mental Health ...... 46 RECOMMENDATION 3.13 ...... 46 Glossary of terms ...... 47 References ...... 48 Appendix 1. Excerpts from MCAPS 2017 ...... 51 Appendix 2. Recommendation of previous reviews ...... 56 Appendix 3. Terms of Reference ...... 109

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EXECUTIVE SUMMARY

Royal Hobart Hospital (RHH) is the second oldest hospital in Australia. The local community strongly identifies with the hospital and staff are proud to work there, most being happy to recommend their families go there to receive their care. In recent years, however, RHH has been in an almost continuous state of crisis with an ever-present risk of serious adverse patient events resulting from intractable access block(1).

The Australian College of Emergency Medicine defines Access Block as ‘the situation where patients who had been admitted and need a hospital bed are delayed from leaving the Emergency Department (ED) because of lack of inpatient bed capacity’(2). An accepted measure is a patient who spends longer than eight hours in ED from time of arrival. The major symptom of access block is ED overcrowding(3) and access block is associated with increased morbidity and mortality(3). Despite the symptoms being most felt in the ED, the cause of access block is a lack of access to inpatient beds, typically through a combination of hospital and system-wide issues involving slow progression of care or “patient flow”(4) both within the hospital and between the hospital and the community.

RHH certainly suffers from extreme access block. From January to March 2019 there were more than 150 patients each month who stayed more than 24 hours in the ED: a single occurrence of which is uncommon in most other Australian Hospitals. In the same period almost 40% of all ambulance arrivals were “ramped”, being unable to offload their patients in an acceptable time frame. Indeed, occasionally all of Hobart’s ambulances are simultaneously ramped at the hospital leaving none readily available for emergencies in the community. We also noted that mental health patients seem to bear a disproportionate proportion of the burden of access block; they are overrepresented in long stay patients in the ED often staying several days in an underground department ill-equipped to meet their needs.

There are many contributors to access block at RHH. First and foremost, the hospital seems to carry an undue burden of health care for the whole of Hobart with an excessive burden of the work being confined to the Emergency Department and within the four walls of the hospital. Staff work in a ‘siloed’ and “traditional” health care system that has not adequately developed the requisite community-based services that should be alternatives to hospital admission. It is not surprising that many clinicians focus largely on the potential for new beds to resolve the access crisis and underplay the potential contribution of improved models of care provided in the patients’ own community.

In addition to the Australia-wide challenges of increasing demand and complexity of care and relentlessly rising community expectations, the RHH and the Tasmanian healthcare system has undergone considerable leadership and governance changes in recent years. These pressures have resulted in loss of collective vision and the development of a politicised and tribal culture that has often resulted in short term, reactive responses to problems. Despite many reviews, substantial improvement is elusive. We found that a high proportion of the staff have, over recent years, been disillusioned with both hospital and health system leadership. On the positive side, however, there is currently a sense that, at the hospital level, this is beginning to improve following a period of relative stability “at the top”. Staff now see some potential for the clinically led “service stream” model introduced in 2017 to make inroads on the many intractable problems.

The loss of collective vision and the persistence of a tribal culture at RHH is compounded by an absence of a shared sense of risk across the organisation. We believe a “blinkered” approach, which sees only the risks directly in front of a clinician and that fails to acknowledge the broader collective risk for other patients (and colleagues) across the system, impairs attempts to improve flow and reduce access block at RHH. This localised view of risk is compounded by barriers to improvement erected in the guise of physician autonomy; “We can’t do this because of college requirements, deskilling of staff, disruption of existing practice schedules, etc.”, Accordingly we have devoted a significant portion of this review to discussing important principles of patient flow, sharing of risk and the need to consider patient outcomes ahead of issues of preserving clinician autonomy.

An essential goal for the design of a health system is to make it as easy as possible for staff to “do the right thing”. At RHH this approach requires strengthening in a number of areas. In information

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Towards Outstanding Care at RHH – Newnham/Hillis technology we noted the absence of a strategy for a digital future with the organisation having no plan for the introduction of a state of the art Electronic Medical Record (EMR). We also noted that inter-unit referral pathways, particularly those involving referral from acute wards to subacute care and admission diversion options are underdeveloped and require confusing and time consuming work and repetition by junior medical staff to ensure that the patient receives timely progression of their care in the most appropriate environment. There is also a lack of agreed “care sets” to guide ED staff in the performance of initial investigation of patients with common conditions. These would help build trust in the inpatient staff that progression of care is reliably underway by the time they are notified of a decision to admit the patient by the ED.

We also found that the staff are currently ill-equipped to deliver the rapid, large scale, whole of system change that is required to address the current access crisis. This combined with the recent infrastructure constraints such as K-block construction, private hospital ownership changes and sanctions within residential aged care has produced a perfect storm of recurrent, critical access block with risk of patient harm that has now become "normalised" within the system.

The relative isolation of the Tasmanian health system brings special challenges. The community expects a full-service system despite the lack of a critical patient load to attract and sustain some specialties and to permit safe volume/safety ratios and strong, regular peer review. The small size of the system (lack of a critical mass) also complicates the provision of adequate system oversight at Tasmanian Health Service (THS) and Department of Health and Human Services (DoH) levels which is challenging even for larger Australian states (5). The absence of board oversight of hospital activities since 2018, places a particular onus on the Secretary of the Department of Health to supplant those board functions and has exposed several gaps. The isolation also contributes to a difficulty in recruiting experienced staff and leaders and exacerbates already limited opportunities to share learnings from across Australia and the global health care system.

This report suggests a number of specific actions to directly improve hospital flow and access. Some of these have been mentioned in earlier reviews. However, like the other reviews we also believe that the strategy to “solve” the crisis involves broader issues of a common vision, leadership, culture, and change management. The strategy includes:

1. Development of a “goal” which all system, hospital, clinical and community health care leaders sign up to in order to drive a more collaborative approach to improvement and change management. This goal should bring the difficult conversations of safety, bed numbers, process improvement, staff satisfaction and adequacy of resourcing into a single conversation with shared accountability for the outcome.

This goal also needs to reflect the interdependence of health care across all sections. We suggest the following:

“The goal is to provide quality, personalised care that seamlessly links the community and the hospital/s, whilst utilising the minimum required hospital capacity, so that the limited resources are used to improve flow, patient outcomes and patient and staff experience.”

Specific recommendations regarding the number of beds required to meet current and future capacity needs are highly dependent on alternatives to hospital admission, community-based care and closely related to models of care(6), and are not to be found in this brief report.

2. Engagement with and education of staff in organisation-wide collaborations to improve understanding and ownership of the principles of patient flow, sharing of risk, development of community-based options for care and the need to put patient outcomes ahead of issues of clinician autonomy.

3. Acknowledgement that, despite pockets of excellence, change management across the system has a very poor recent record and requires attention, including external assistance.

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4. Engagement with external experienced organisational mentors such as the Institute for Healthcare Improvement (IHI), or the High Reliability Organisation (HRO) or interstate agencies that have an established record of successfully guiding system change and developing a “can do” culture in a broad mix of jurisdictions within an acceptable timeframe.

5. Investment in finding, developing and empowering effective leadership to manage change as much as possible within local staff. This needs to be supported by clear governance and accountability, recognising that this development may best be facilitated by external experienced mentors from other regions of Australia or globally. It also needs to be supported with appropriate allocation of non-clinical time to do the leadership and improvement work.

6. The initial focus of change management expertise should be on

a) Establishing a committee charged with implementation of the recommendations of this review together with the outstanding high priority, still relevant recommendations of previous reviews (see Appendix 2). This committee should be chaired by the Secretary and include senior hospital administrative and clinical leadership and community representation implementing quick wins within 90 days and other recommendations within 2 years.

b) “Quick wins” that are achievable and likely to have almost immediate impact on access block:

i. Changes to the General Medical model of care (page 44) – including continuous distribution of patients across all four teams, re-rostering of registrars to provide improved 24/7 cover, simplified referral processes to subacute care (page 41).

ii. Reduced bed clean and turnaround times (page 39).

iii. Work towards an agreed ‘high performance’ 4h non-admitted patient target in the ED (page 34).

iv. Shift the site of stroke thrombolysis treatment from ICU to the stroke ward (page 42)

v. Establish a single hospital-wide HITH-like service with integrated medical, nursing and allied health support that supports patients at home and within residential care (page 30).

vi. Include Southern Hub and Northern Hub hospital leads on the THS executive (page 12).

vii. Schedule daily consultant geriatrician rounds through ED and EMU to facilitate admission diversion plans for complex elderly patients and upskill ED staff on alternative pathways of care. (page 34).

viii. Development of agreed ‘care sets’ across the ED and inpatient units for the most frequent clinical presentations that will enable the agreed admission of patients to the ward under the appropriate clinical unit. (page 36).

ix. DoH/THS should resource “protected” surgical stream beds that do not compete with acute admissions in order to meet elective surgery targets. This will likely require greater collaboration with private hospitals in the short and medium term (page 46).

c) Hospital flow and access including the recommendations of this report and the still relevant recommendations of previous reports (see Appendix 2, page 56). Some of these are underway following the Access Solutions Meeting of 19th June 2019.

d) Development of a digital health strategy that includes a fit for purpose electronic record and staff communication platform.

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e) Development/enhancement of highly accessible community-based health care services that link seamlessly with hospital services (beyond the HITH service discussed in “quick fixes” above) including services that provide comprehensive care for mental health patients. This should be consistent with the “One State, One Health System, Better Outcomes” approach and be “visible” to staff managing patient flow across the system.

f) Developing/advocating for funding models that support/incentivise the above.

Finally, we note that Tasmania (and Hobart) has many inherent ingredients in common with Scandinavian and European systems that are global leaders in healthcare and deliver excellent care from a strong base in the community. These ingredients include a single provider of public hospital services, all of which are connected by a single digital record (admittedly outdated), a single ambulance service, a single primary health care network, a relatively homogenous population with strong roots and deep commitment to their local community, a pristine environment, a low level of traffic congestion and attractive cities in which staff are keen to live and work.

We believe that Tasmania, led by the RHH, should aim to become an Australian leader in seamlessly integrated community, primary, subacute, mental health, rehabilitation, and acute health services within the next 10 years. We encourage Tasmanian system leaders to seek federal collaboration (including the Primary Health Network) to utilise Tasmania’s inherent ingredients to establish a best-practice model of truly integrated community-based care as an “incubator” of innovation for the rest of the country to learn from.

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Towards Outstanding Care at RHH – Newnham/Hillis

PREFACE

This reviewing team was first contacted by the Tasmanian Secretary for Health, Adjunct Professor Michael Pervan, on the 28th April, 2019 following concern arising from the death of a patient in the ED waiting room of the RHH some weeks earlier. This and other adverse events in the ED were increasingly being attributed to worsening access block by the media and the unions. Politically, there was a profound frustration that the situation was worsening despite a decade of prior reviews, significant investment and many recommendations for improvement. These political pressures escalated in the early weeks of our review with the Health Minister at that time being subjected to a twelve-hour debate of “no confidence” in the Tasmanian Parliament.

In this complex setting we were invited by Dr Jodi Glading, Deputy Chief Medical Officer Tasmanian DoH, to review the underlying causes of the persistent access issues at the RHH, and to discern the reasons why the recommendations of the “Patient’s First” initiative and of many previous reviews had not led to acceptable improvement. We were also invited to a solutions workshop, the “Access Solutions” meeting, held in Hobart on 19th June, 2019 which was co-chaired by the Tasmanian Health Minister and the President of the Australasian College for Emergency Medicine and was designed to bring together many of Tasmania’s health leaders to formulate an action plan to definitively resolve RHH’s access issues.

We visited RHH the THS and DoH on 21st and 22nd May and the 3rd-5th June, 2019. During those visits we conducted 37 interviews involving more than 70 staff. We would like to acknowledge the warm reception all the THS, DoH and RHH staff gave us over the four and a half days we spent at RHH as well as on the day of the Access Solutions meeting. We were impressed by the willingness of staff to contribute meaningfully to this review and their eagerness to see real progress for their patients and the hospital. We would particularly like to thank Sharyn Cody, Director Executive Strategy and Planning,THS, who organised our visits and provided access to a vast array of informative data.

We also acknowledge the extensive work of the previous reviewers and also the strategic planning work shared with us by Ms Nicola Dymond, THS Chief Operating Officer, all of which have helped greatly to inform this review, and parts of which are quoted in our text (see Appendix 2).

About the reviewers

Professor Newnham is a clinical leader with Program oversight over the Emergency Departments, ICU, General Medicine and Hospital-in-the-Home services at Alfred Health in Melbourne, Victoria. He worked with Stephen Duckett of the Grattan Institute to produce the “Report of the Review of Hospital Safety and Quality Assurance in Victoria”(5) in 2016 that has led to substantial changes in the approach taken by the Victorian Department of Health and Human Services the governance of health care in Victoria. Harvey is on the boards of Melbourne Health and Better Care Victoria, (an advisory board to the Victorian Health Minister on innovation in healthcare), as well as the not-for-profit Health Education Australia Limited (HEAL) which also administers the Australian Institute for Clinical Governance (AICG).

A / Professor Hillis of Oban Consulting has substantial experience as a medically trained, senior executive / CEO of health facilities across Victoria and also CEO roles within the educational sector. He has consulted broadly on organisational design, cultural and change management issues as well as having broad governance experience across community, health and educational organisations.

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REPORT FINDINGS

1. System and Organisational Enablers

Background and “re-thinking the vision”

System leadership should foster a clear vision and direction for the health service that seamlessly integrates hospital and community care.

The existence of this further review of the challenges confronting the Emergency Department at Royal Hobart Hospital reflects the ongoing crisis of access block across the Tasmanian Health Services (THS), particularly within its Southern Hub of Health Services. The distressing lack of resolution of this crisis is now impacting on political accountability, health policy debate, significant and life-threatening concerns around patient safety, staff morale, community support and community anxiety throughout Tasmania and beyond.

Pressures on Emergency Departments and access beyond them into acute hospitals, sub-acute care, mental health, rehabilitation and community-based care are being felt internationally(7). The finite resources of the health sector are being forced to meet rising community expectations for better, safer, timely care in an ageing population often with multiple, complex chronic illnesses, inevitably creating tension, bottlenecks to patient flow and capacity challenges that all work together to produce access block. Since the introduction of ED performance measures in the form of the “4 hour rule”, introduced almost twenty years ago by the NHS(8), EDs have been the primary focus of attention because that is where the queues predominate, even though the causes of access block typically involve whole system function(9),(10). Australia started to introduce similar measures almost ten years ago(11) and Australian EDs have similarly suffered the spotlight of attention from those looking for a ‘quick fix’.

A substantial and repetitive body of literature details the many approaches taken to improve ED access block and the difficulties encountered in doing so(12). The more successful approaches acknowledge that solutions to ED overcrowding are to be found mostly outside the ED(9) by aligning the strategic requirements of Population, Capacity and Process(13). They require a systems wide view, strong leadership, sophisticated skills in change management, clinical engagement and staff empowerment. Clinicians need to be accountable not only for their actions with their individual patients, but also for progressing broader goals of safety, quality and timely progression of care for the entire health service in which they work. Clinicians cannot provide their “best” care unless they are part of a highly organised and efficient health care delivery system seamlessly integrated within the community they serve.

Many of the warning signs of “service failure” identified by the Commission on Delivery of Health Services in Tasmania(14) are still evident at least to some degree in RHH’s ongoing access crisis. These include: low levels of accountability, poor working relationships, closed culture, poor strategic risk management, lack of clarity, poor information for decision makers and poor leadership not to mention increasing concerns for patient safety. Following the publishing of the 2014 report there has been considerable effort, organisational change and resources expended in variably successful attempts to improve outcomes for Tasmanian Health. Unfortunately, many of the warning signs remain and now add to the checklist of challenges that still need be addressed to achieve sustainable improvement. Similarly, the Auditor General, in his recent report on the Performance of Tasmania’s four major hospitals in the delivery of Emergency Department services, highlights the connection between access block and the importance of good leadership, clarification of roles and responsibilities, empowerment, collaboration, change management, team work and coordination across departments and services(15).

RHH staff told us, on many occasions, that ‘we do not do change well’ and that the ‘clinical services are very in-patient focused’. There was a widely held view that much more could be done to help RHH interface more effectively with the community to reduce pressures on inpatient capacity.

During our visits it was clear that RHH staff see some light at the end of the tunnel. The implementation of the ‘clinical service stream’ model over the last two years has led to greater clarity in clinical

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Towards Outstanding Care at RHH – Newnham/Hillis leadership and is going some way to developing a more systematic approach to addressing current problems. The pace of change remains slow. In the face of an intolerable access situation almost all attention continues to be on the hospital itself rather than potential alternatives to hospital admission.

The physical redevelopments at RHH including the new K block are nearing completion and have further narrowed the staff and public focus on the hospital itself as representing the “whole” health service. Expectations in the public and staff are high that the bricks, mortar and the beds that come with them will solve the current problems. Unfortunately we agree, along with many others that have experienced new capacity developments, that these infrastructure improvements will have only a transient effect on improving the situation, and that addressing the challenges above, particularly looking to alternative models that reduce inpatient bed utilisation and improve community-based care is vital to resolve the situation. This can start happening right now, regardless of the inpatient bed situation.

Many of the staff we spoke to were unable to articulate the vision of the organisation/health service and perceived that the system and hospital leadership were also unclear about the direction in which the RHH was heading other than solving day to day crises. In our view, a key to making progress on all the above challenges is for the health system and hospital leadership and staff to come to an agreed understanding of the goal of the organisation and to focus and prioritise strategic planning and development decisions towards achieving that goal. The reviewers recommend the following goal as the starting point for discussion:

“The goal is to provide quality, personalised care that seamlessly links the community and the hospital/s, whilst utilising the minimum required hospital capacity, so that the limited resources are used to improve flow, patient outcomes and patient and staff experience.”

RECOMMENDATION 1.1

The Secretary of the Department of Health and senior clinical leaders commit to a vision of a highly integrated health service from the acute through sub-acute and mental health sectors to the community

Establish a committee charged with implementation of the recommendations of this review together with the outstanding high priority, still relevant recommendations of previous reviews (see appendix 2) within 2 years. This committee should be chaired by the Secretary and include senior hospital administrative and clinical leadership (including Mental health) and community representation.

Lack of Clarity in Governance

Governance and organisational structure should promote effective strategic planning and empower organisational, service and unit leadership to deliver strong oversight of safety, quality, finances and risk and patient and staff satisfaction.

Over the past ten years, the Tasmanian Health Sector has had several substantially different governance and service delivery models. The current model has removed a Board structure and CEO. It now has the RHH Chief Operating Officer (COO) reporting through the THS COO (who sits on the three member THS executive) directly to the Secretary of the Department of Health who in turn is responsible to the Minister for the performance of the THS and the Executive(16). The breadth of the role of the Secretary required to fulfil the equivalent of board oversight on each hospital in Tasmania is now most substantial and onerous. It requires a governance framework to support performance monitoring and management of the THS across all the traditional components of board oversight. It is hence no surprise that gaps and uncertainty in roles and responsibilities exist. For example, it is sometimes unclear which decisions sit with the RHH COO as opposed to the THS COO or the Secretary, etc. As

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Towards Outstanding Care at RHH – Newnham/Hillis a result, communication and timely decision making is a constant challenge and often leads to frustration amongst RHH clinical leadership.

Also reporting to the Secretary are all the requirements of the Department of Health (DoH) as well as the accountabilities and responsibilities of the Tasmanian Health Service. There is substantial uncertainty regarding the respective roles of the Executive of the DoH and the previous THS senior Executive and staff with some duplication of reporting and line management responsibilities. For example, there appears to be some uncertainty regarding responsibilities for overall “risk management” at the THS executive level. This is also evidenced by enquiries of the Press and the Minister of Health’s office frequently being directed to the Royal Hobart Hospital Executive and clinical staff. The roles and responsibilities of the DoH/THS/Clinical Hubs need to be clearly articulated in accessible and transparent documents.

The THS and the DoH are both important in developing and ensuring the successful monitoring and implementation of state-wide developments but, in a small state like Tasmania, their co-existence risks constituting a “top heavy” approach to governance with attendant risks of duplication, inefficiency and disempowerment particularly of local hospital management. A consistent approach with strong engagement of both administrative and clinical leadership is needed to progress the worthy plan for the ‘One State, One Health System, Better Outcomes’ strategy(17). This strategy places THS and DoH in the key role of reducing the variation in care and rationalising the services across the whole system to allow early detection and prioritisation of opportunities for improvement.

A good example of the kind of work needed to support the planning component of the “One State” strategy is found in the detailed data output of the previous Oak Group International’s “Making Care Appropriate for Patients” (MCAP) tool under the guidance of the THS COO, (see page 19 for discussion) and also the prior UTAS review, particularly the “Why am I still here” and “Who owns the time line” components(18). It seemed to the reviewers that this promising MCAPs work and the important decision making that should flow from it, were both receiving insufficient attention.

Another area receiving scant attention is Human Resources/recruitment processes at RHH. Good staff are the life-blood of any organisation. Unfortunately for the clinical leaders at RHH, the process of staff replacement and new recruitment is both time consuming and disheartening because of the many outdated, bureaucratic and inefficient steps required. We heard that it can often take seventy days just to recruit a new nurse. On top of this, budgetary fears often limit the tenure of new appointments to just one year. This is a false economy because of the high administrative and quality costs of consecutive short term appointments.

Together, these barriers make it difficult to attract talented staff from interstate or internationally. Many staff are suspicious that these inefficiencies in recruitment are tolerated by “administration” because they typically reduce costs, forcing existing staff to pick up other roles for the duration of the recruitment process. Rather, safe high quality care together with timely patient flow and staff satisfaction may be sacrificed along with the added penalty of increased overtime/locum/agency costs which result from these inefficient staff recruitment practices. This is particularly likely when experienced staff are missing at important organisational bottlenecks to progression of patient care.

RECOMMENDATION 1.2

Recruitment processes be revised to ensure a nationally competitive, timely and responsive appointment cycle

Review and minimise the current practice of making short term appointments for clinical staff operational roles.

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Financial governance at RHH is also a concern. Most of the clinical leaders we spoke with felt that they did not have enough control of the cost centres for which they were responsible and that they were not sufficiently involved in budget-setting negotiations. This perception seems to disempower these clinical leaders from decisions directed to process improvement and for “spend to save” initiatives. Much work has been done to understand budgets and match allocations to the work achieved, but there appears to be a long way to go. The elephant in the financial room for RHH currently is the need to rapidly adapt to the new Activity Based Funding (ABF) to ensure that all revenue opportunities are fully realised. We understand that poor engagement and limited financial education of clinical staff in the areas of ABF and the necessary accuracy of coding requirements, together with the challenges in negotiating private practice entitlements and limited “back room finance resources” are together resulting in RHH foregoing annual revenue in the order of several million dollars.

Although these reviewers are reluctant to suggest any high level governance changes in this environment of chronic instability that we have already highlighted, there are some that we believe would be productive. Given the substantial profile of the ‘Northern’ and ‘Southern’ Hubs, the Secretary should have direct line management responsibility for both. Accordingly, the senior manager of each of these services should be part of the THS Executive Team reporting directly to the Secretary. Whilst the Strategic direction, Service planning, Performance Management and Clinical Governance should all sit centrally, we believe the Senior Hub operational managers, who would currently be one of the respective hospital COOs in each Hub, should also have direct input at this most senior Executive level.

Mental Health at RHH seems to sit strangely outside the acute operational structure of the organisation. Mental Health is administered centrally and its governance is confusing to many staff including those responsible for managing patient flow in the rest of the organisation, who do not seem to be in a position to transparently view mental health access pressures and available options. For the unfortunate and increasingly common group of mental health patients who simultaneously suffer an acute medical/surgical issue requiring hospitalisation at the time of an exacerbation of their mental health issues, there is often a grey zone of confused accountability for their management and bed utilisation that leads to a “stalemate” between managers on either side of the acute or mental health divide. As a result, mental health patients are over-represented amongst those patients having a very long stay in the RHH ED or wards, because of access block. Although the clinical lead/manager of the southern component of the Mental Health program does meet periodically with the COO/deputy COO of RHH, we believe a much closer and more regular communication channel with all the clinical leads, those in charge of patient flow, and operational management would be highly productive.

The THS is working to introduce Integrated Operational Centres (IOCs), with oversight of patient flow and access both within and across the hospital system. We strongly encourage further development of this work by combining currently available data with visibility of options for admission avoidance in the community and early discharge to or from subacute care back to community-based care for both acute and mental health patients.

An additional approach to empowering and informing local ward clinical staff and fostering good leadership used in some hospitals is to institute a “Good Ward Governance” program. This includes an “Accountable Care Unit” (ACU)(19) approach in which a physician manager and nurse manager share responsibilities and accountability for all ward patient and quality outcomes and budgetary responsibility as well as fostering interdisciplinary education and staff orientation. Essentially the physician manager works with the nurse manager to ensure appropriate engagement with all staff and lead local long stay patient and quality incident discussions. In larger units these two leaders are supported by a monthly interdisciplinary leadership meeting with uniform agenda across the organisation to aide support of organisational priorities and national standards. Good Ward Governance practice also extends to defining expectations for ward rounding times, consultant presence and safety and quality checklist utilisation whilst on rounds.

We acknowledge the many recommendations of previous reviews on this topic (see Appendix 2 for summary).

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RECOMMENDATION 1.3

Identify where the former board roles to support and appoint the Executive Director of Operations (or equivalent manager), and provide oversight of quality and safety, risk management, strategy, audit, organisational culture, consumer advice and financial responsibility reside in the current THS/DoH structures. Regularly monitor and transparently report on them.

Adjust the governance of the THS and Northern / Southern hubs by having the senior manager of both the ‘Southern Hub’ and the ‘Northern Hub’ on the THS Executive, thus reporting directly to the Secretary.

Clarify the role of the Senior Executive at the Southern Hub / RHH to ensure that all clinical services including Mental Health, ambulatory care and community services are appropriately integrated into the clinical executive structure.

Hold the senior clinical leadership accountable for operational efficiency, budgetary, safety and quality portfolios and activities that contribute to patient flow within their streams by developing relevant KPIs that are reflected in detailed annual performance reviews.

Introduce a “Good Ward Governance” program in which unit/ward interdisciplinary leadership teams (medical, nursing, allied health, pharmacy) meet monthly with a standardised agenda and quality reports, and are responsible at local ward/unit level for reviewing performance, improving patient flow and implementing other improvements as agreed by the hospital clinical leadership executive.

Engagement and Empowerment of staff / clinicians

Meaningful clinical engagement requires empowerment through supported time, training, communication and provision of opportunities to contribute to organisational development.

RHH should aspire to be seen as a “great place to work”1

Since the early days of hospitals, physicians have had a very long tradition of focussing predominantly on the care of the patients in front of them whilst delegating the remaining aspects of care to “administration”. The Administration is “expected” to look after nursing, allied health, pharmacy and all the hotel requirements of the patients so the doctors can “get on with the job”. Most clinicians base their daily approach to their work largely on good examples of care that they have seen in the respected mentors who trained them in combination with peer review from their colleagues, as well as what they glean from the evidence-based medicine in the literature or from conferences.

In recent decades there has been a major shift in the role of the clinician. It is no longer possible for an administration to “run” a successful hospital without deep engagement from clinicians. The learnings from medical training and the clinical literature must always be extended to include an in-depth understanding of both how the health system works and how it can be improved. The “situational awareness” of all clinicians to identify safety and quality hazards or workarounds that indicate a risky or inefficient process is in place is crucial to developing excellent patient outcomes and a professionally satisfying workplace. Underperforming hospitals commonly have a low level of clinical engagement(20).

Because of the essential importance of clinician engagement, many approaches to developing and sustaining it have been reported nationally and internationally(21). Some aspects of key importance identified by one from the NHS (see Figure 1) are reproduced below.

Our conversations with clinicians at RHH revealed highly variable levels of clinical engagement. Although all staff we met had a strong patient focus and want to see access block “gone”, the degree

1 This is part of Royal Melbourne Hospital’s vision statement.

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Towards Outstanding Care at RHH – Newnham/Hillis of engagement with and respect for “the administration” ranged from the strongly positive (particularly positive comments were repeated regarding the recent service stream structure) to the outright dismissive. It became clear to us that many prior recommendations had failed not because they were bad ideas or inappropriate for RHH, but because they were perceived to have been “sent by decree” from administration or system managers without the serious or effective attempts required to have clinicians “own the process” necessary for a sustained improvement.

Selecting and appointing Developing a the right doctors to future-focused and Leadership leadership and management roles outward-looking culture Stable, top-level leadership that Selecting through open Encouraging and engaging in promotes and fosters competition ensuring a choice best practice, and promoting relationships, sets expectations of candidates and appointing and contributing at regional and and leads by example based on ability, attitude, national level leadership aptitude and potential

Promotion of Providing support, understanding, trust and development and respect between doctors leadership opportunities and managers to doctors at all levels Engaging Developing an acknowledgement and Investing in training, mentoring acceptance of professional and coaching, ensuring formal Doctors differences, ensuring managers and informal leadership and doctors share a common opportunities are available goal to deliver high quality healthcare to patients

Setting expectations, enforcing professional Clarity of roles and Effective behaviour and firm responsibilities and communication decision-making empowerment Ensuring organisational Building trust and developing Ensuring doctors and expectations are clearly relationships through open, managers work together, are communicated and that issues honest communication and that accountable and empowered to relating to unprofessional is persistent, widespread and shape and develop the behaviour and patient safety inclusive organisation are dealt with quickly and decisively Figure 1

Relationships underpin how organisations work as a team. At RHH and within the THS there appears to have been a breakdown in relationships between the senior clinicians and the system leadership with significant loss of trust and respect. In our view this breakdown in relationships has been and still is a serious contributor to the current problems at RHH. In particular, we felt there was a distinct reluctance for leaders to respectfully hold the many difficult conversations required to address the sorts of problems RHH is currently experiencing or to call out disrespectful or dysfunctional behaviours as soon as they occur.

“The standard you walk past is the standard you accept” - Lieutenant General David Morrison, Chief of Army, 2013

On the positive side, the current serious challenge of ED access block at RHH has mobilised many clinicians who are now looking for opportunities to engage in improvements and acknowledging the need to explore new avenues of approach. In our view this common goal and serious threat to RHH provides a rare opportunity for system administrators and lead clinicians to “sit in the same room” and

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Towards Outstanding Care at RHH – Newnham/Hillis jointly work out solutions simultaneously whilst resolving their differences. Indeed, any who are not prepared to do so in a meaningful way should be seriously questioned regarding their commitment to Tasmanian healthcare.

In many of our discussions with clinical unit heads at RHH we were surprised to find that, unless they were service stream leads, they typically indicated that they had no formal “non-clinical” time allocation to lead their respective teams, although they did receive a minor boost in overall remuneration. In the Victorian award(22), non-clinical time is a standard requirement for most public hospital clinicians with substantial full time equivalent positions (>50% EFT) and is particularly proportioned to unit heads (up to 50% for large units, pro rata according to EFT) to facilitate strong team leadership of not only their team’s clinical work but also all the necessary portfolios of quality and safety, staff management and rosters, education and other activities for a successful service. In our view it is not possible to hold clinical leaders accountable for these activities unless there is appropriate non-clinical time allocation to support them. Lax documentation regarding availability of non-clinical time may also reduce the attractiveness of RHH staff positions to interstate applicants.

There was significant investment in clinical leadership during the previous THS structure. It is unclear why this investment did not result in the expected clinical improvements. RHH still provides leadership training and professional development for various clinical leadership roles in the organisation, particularly for nurse leaders. The availability and quality of these is apparently quite variable and staff were of the impression that their overall quality has declined in the last few years. It seemed to us that, for most senior medical staff, the hospital expected them to individually seek professional development training in leadership and improvement science, should they happen to be interested. In addition, there seemed to be very limited opportunity for aspiring leaders to rotate for 6-12 months into safety, quality and innovation/improvement roles to develop serious expertise in these areas. The reviewers believe there is much to be gained by raising the expectation that leaders and those aspiring to lead receive good quality training and ongoing professional development to do so. This should be reflected in position descriptions, job advertisements, interviews and during annual performance appraisals. For leadership to thrive however, there will also need to be further building of trust between clinical and system leaders.

We believe that the staff of RHH would benefit from the opportunity to interact with the system and hospital managers in person on a more regular basis. Monthly or bimonthly “Executive Road Shows” in which senior administrative and clinical leaders, and occasionally system leaders, outline current organisational priorities and directions for the future in a theatre style session with substantial opportunities for ad lib questions from the staff, preferably using an anonymous digital format, could go a long way to having all “on the same page”. This activity would also encourage clinical engagement and the uncovering of simmering issues that might otherwise undermine good works.

RECOMMENDATION 1.4

RHH should insist that those in leadership positions provide evidence of ongoing professional development in leadership and improvement science skills.

This should be reflected in position descriptions, job advertisements, job interviews and during annual performance appraisals.

Senior leaders should be given the opportunity of mentored leadership training with appropriate local or national agencies.

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RECOMMENDATION 1.5

Clinical leaders including unit heads and substantial FTE clinical appointees should have non-clinical support time that reflects their responsibilities for portfolios including staff management, safety, quality, improvement/development, education and research duties – up to 0.5 EFT for heads of very large and complex units and 0.2 EFT for other full time appointments.

The expectations of these non-clinical roles should be clearly defined and these staff should be held accountable for their achievements in these portfolios during annual performance reviews.

Hold second-monthly “Executive Road Shows” open to all staff in which senior administrative and clinical leaders, and occasionally system leaders, outline current organisational priorities, performance initiatives and directions for the future.

These should be held in a theatre style session with substantial opportunities for ad lib questions from the staff, using an anonymous digital format.

Culture

Development of a “can do” culture of continuous improvement of patient safety, flow, interdisciplinary teamwork and interaction with primary care and community services is essential to the future of RHH.

The development of a future-focused and outward-looking culture is a critical component of the Engaging Doctors framework (Figure 1). Culture is often described as the ‘way we do it here’.

The recent banking royal commission in Australia has identified the key responsibility of all boards to manage the culture of the organisations they serve. RHH now has no board and it is unclear who is responsible for the cultural improvement in the organisational although there is evidence of work in this direction with the recent adoption of the ‘Magnet’ cultural change model directed towards nursing staff.

Clinicians described both themselves and the RHH as often feeling as if they were ‘under siege’. During the recent period of frequent change in senior Executives several parts of the organisation have developed a strong sense of “tribalism”(23) with a destructive tendency for tribes to push “blame” for problems and hence accountability for resolving them onto others i.e. a “not my problem” approach. This tribalism came in many forms: between clinical siloes of care (ED vs ward staff or acute vs subacute staff), between junior and senior staff (or vice versa) or between clinicians and managers; but was a common theme in many of our discussions. Whilst pride in one’s tribe and a close sense of teamwork can be a positive outcome of tribalism, these negative characteristics reflect poorly on RHH culture and seriously hamper effective change.

Our discussions with some clinicians also revealed a strong perception that local “clinical autonomy” was of utmost importance; indeed, it often seemed as if it “trumped” excellence in patient care. For example, proposed changes in workflow that have been demonstrated to improve patient outcomes may be discarded because of their perceived impact on various college training requirements, current work practices or conflict with union/AMA recommendations. Brent James from Intermountain Health Care often repeats the comment that “clinician autonomy kills patients every day”. His basis for saying so is that when clinicians uphold their right to practice individually (or tribally) as they see fit, there is typically substantial variation in the patient care provided. This variation in care is like a “fog” that makes it impossible to discern what is or is not working well and hence it is impossible to learn from current practice. An understanding that day to day clinical work involves many processes of care, all of which may have opportunities for improvement is fundamental to developing an organisational culture of continuous improvement. RHH should aim to become a “continuously learning organisation” where lessons are learnt as quickly as possible by reducing variation in care, enabling the identification and

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Towards Outstanding Care at RHH – Newnham/Hillis implementation of opportunities for improvement. What is required is that clinicians put patient outcomes first and workshop any potential barriers to new workflows that can deliver this outcome in order to resolve them. Obstructive tactics based on “clinician autonomy” need to be immediately called out for what they are so that patient outcomes are the first priority. This is part of the “difficult conversations” referred to above.

During the period of our review a senior clinician from Logan Hospital (QLD) was reciprocating a visit. Logan is a dynamic Queensland Health organisation currently managing a period of rapid change with alacrity. This kind of interaction with external organisations is of great value to all healthcare services(24). These opportunities to exchange ideas regarding improvement and application of “fresh eyes” to local work should be fostered as much as possible at RHH.

Culture starts from the top. We emphasise the importance of political, system and hospital leadership articulating and “living” a clear goal for the organisation as described in our earlier discussion. This includes respectful discourse throughout the organisation. There must be a willingness at all levels to “call out” destructive tribalism and disrespectful behaviour when it happens (i.e. yet another difficult conversation). We understand that the head of People and Culture at THS has recently left and would encourage timely recruitment of a high quality replacement.

The change to a ‘can-do’, ‘patient-centred’, ‘teamwork-orientated’, and ‘respect-based’ culture takes time. RHH faces the challenge of becoming an “inclusive” organisation with all staff feeling empowered to call out issues of safety and disrespectful behaviour and to feel as if they are all on the same team, working to continuously improve patient outcomes. Only then will RHH become a “great place to work”.

RECOMMENDATION 1.6

The Department Secretary commits to, and resources, an ongoing cultural change program fostering both a “can-do” culture of continuous improvement in patient outcomes as well as RHH becoming a truly “great place to work”.

Strengthen and resource the governance, leadership and capability of health service delivery improvement at RHH, with initial focus on improving hospital flow and access.

Encourage reciprocal staff visits to, and communication with, exemplar hospitals

Barriers to improvement based on arguments of “clinician autonomy” need to be immediately called out for what they are so that better patient outcomes become the first priority.

Change necessity

Good ideas must be supported by effective change management across the whole health system

Change management is difficult and prone to failure(25). The main reasons are lack of a clear vision of the change initiative’s desired outcome, lack of support within the organisation, poor alignment with underlying organisational needs or insufficient financial resources. It is important to have successes with change: failed change management strategies result in poor employee productivity and morale, increased staff turnover and negative financial impacts. In the absence of good successes change fatigue and cynicism sabotages future organisational development. The literature is ‘rich’ with models to support change management. The crucial component is that the leadership and teams introducing the change acknowledge that a framework is required, they are trained in how to achieve it, and can strongly counter ‘push-back’ or ‘lack of engagement’.

“We don’t do change well” - RHH clinical leader

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In our discussions with RHH, the above quote was often reinforced. Most staff are frustrated with the slow pace of effective change. They do not have a clear understanding of how the organisation approaches change nor how to initiate it in their own environment. Given the plethora of review recommendations from previous reports on healthcare in Tasmania that remain to be successfully implemented or have been poorly sustained (see Appendix 2 for summary), we concur that RHH has a poor record of achieving change. The Kotter model(26) emphasises the importance of three key steps: Creating a climate for change, engaging and enabling the whole organisation and implementing and sustaining change (Figure 2). In this model, current evidence would indicate that RHH has not progressed much beyond the first two steps of “creating urgency” and “building a team” (which could be considered to be the clinical service stream leads). In Kotter’s framework, RHH’s iceberg continues to melt(27).

We acknowledge that there have been prior attempts to enhance change using “fly-in” experts that have had limited success and that external support is not a substitute for developing good local leadership. Nevertheless, in the face of the current access crisis, we believe there is an urgent requirement for RHH to seek sustained, rather than short term, external support to kick start the development of an effective culture of change. We suggest that the THS/DoH enlist the help of a capable external agency to support RHH for the next 2-3 years to both implement a change management program focussed on improving patient flow and also to develop local leadership skills and capability to embed the capacity to succeed in future change as part of a continuously improving and learning organisational culture. It is notable that Safer Care Victoria is currently working with the support of the Institute for Health Improvement (IHI). Perhaps opportunities for collaboration with SCV could be explored.

Kotter Change Management Model Implementing and Engaging & enabling sustaining change the whole organisation Creating a climate for change

1 2 3 4 5 6 7 8

Increase Build the Get the Communicate Empower Create Don’t let Make it urgency guiding right for buy-in action short-term up stick team vision wins

Figure 2: The Kotter Model

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RECOMMENDATION 1.7

Acknowledge that, despite pockets of excellence, change management across the system has a very poor recent record and requires serious and systematic attention.

The THS/DoH enlist the help of a capable external agency (e.g. IHI) to support RHH for the next 2-3 years to both implement a change management program focussed on improving patient flow and also to develop local skills and capability for future change. Opportunities for collaboration with interstate agencies should be explored.

That change management to improve patient flow should extend outside the hospital to the development of responsive community-based healthcare services with funding models that incentivise these changes.

Improve the voice of the consumer

Engaging consumers in design and delivery of care is essential for the development of timely, effective and safe care pathways that minimise waste and avoid unwanted and inappropriate care.

RHH has a capable consumer advisory group that is keen to be more involved in the hospital and its activities. Integrating consumer engagement with significant hospital activities is a good way to ensure their contribution is noticed and supported and to avoid a common criticism that engagement is merely “tokenistic”(28). Such activities could include focussed consumer feedback, analysis of clinical events, staff selection interview panels and co-design improvement activities.

Current approaches to patient feedback in Australia often have an organisational or ward focus rather than a unit or team focus and are built around specific sets of questions. Their non-specificity often means they receive scant attention by busy clinicians who may consider the feedback refers to someone other than themselves. An alternative approach is to invite patients and their families/carers in groups to provide face-to-face focus group feedback to the medical and nursing leadership of the teams who provided their care. We strongly encourage RHH to consider taking this approach on a biennial basis at least for each of their major services. The focus groups should be led by an experienced facilitator and not by the clinicians themselves.

All clinical events involve a patient/family or carer. The root cause analysis evaluation that is conducted of adverse clinical events is enhanced by inclusion of a consumer to see things from the patient perspective. We encourage RHH to take this approach.

Abundant literature promotes the concept of “co-design” of improvement and development work with meaningful involvement by the consumer, which we also endorse(29).

Some Australian health services are experimenting with including consumers on interview panels for medical including non-clinical medical positions. Consumer presence at these interviews can help focus attention on core patient care issues and communication skills, avoiding excessive focus on technical and academic skills.

Patients should also be asked to take responsibility for their own care progression as much as possible. For patients in ED, the wards or an outpatient clinic it is common for the next planned step in their progression of care to go awry. For example, a patient in the ED may have had blood tests taken with results available, but as a result of change of shift no clinician is assigned to follow up results so the patient might wait for hours before anyone realises. Or a patient has improved and someone forgets to organise their departure/write their discharge communication. These time consuming delays can be minimised by adopting an organisational wide practice of not leaving a patient’s bedside without explaining the steps they should expect to happen next, who they should contact if care isn’t progressing as planned and who is the lead clinician in charge of their care.

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RECOMMENDATION 1.8

Each major clinical service at RHH should host a biennial consumer forum chaired by trained facilitators, (ideally consumer leads), and attended by unit medical and nursing heads aimed at adapting care processes to meet consumer concerns.

Consider including consumer representatives in Root Cause Analyses and formulation of recommendations regarding major clinical events and resourcing the required consumer training.

Consider including appropriately skilled consumers on interview panels for medical and substantial non-medical leadership positions at RHH.

Include consumers wherever possible in organisational improvement design initiatives and resource the required consumer training.

Empower patients to call out unexpected delays. Establish the practice of informing patients of what will happen next before leaving the bedside; what they are waiting for, and how long the wait is expected to be so that if it doesn’t happen they can call it out. Ensure each patient knows the name of the clinician in charge of their care

Data / Information / IT

Skilled interpretation of readily accessible, trusted, clinical, financial and administrative data is essential for good system management and improvement of patient flow.

The reviewers were surprised at the marked variation in data quality available to the THS/DoH and RHH. On one end of the spectrum there was the very high quality and informative strategic data of the MCAPs report of 2017 and the similarly informative work of the HRC University of Tasmania report from 2014. We were encouraged to hear that the MCAPs work is on the verge of being more widely implemented and available in an ongoing basis, a development which we thoroughly applaud. These data provide clear insights regarding opportunities for improvement and are discussed below.

On the other hand, we were shocked to find that RHH’s digital record still relies on scanned documents, paper-based request ordering and has minimal built in decision support. It was even more surprising to note that there is no current strategy to progress RHH and other Tasmanian hospitals to a true Electronic Medical Record (EMR). We consider this latter omission a major strategic risk for RHH and a significant handicap in efforts to improve safety and quality of care including the reduction of access block.

The Oak Group International MCAPS tool’s data (see excerpt Appendix 1) offers intriguing insights into current models of care and the ongoing debate about optimal utilisation of scarce health care resources in Tasmania and hence deserves more detailed discussion here. The MCAPS tool refers to qualified and non-qualified patients. Qualified patients are those who are ‘at the correct level of care to meet his/her medical needs’. Unqualified patients are those that ‘could be treated at a different, usually lower level of care to meet their medical needs’. The 2017 data (see excerpts in Appendix 1) were notable for a number of findings relevant to this report. The overall “non-qualified” admission rate of 16% indicates that these patients, according to international criteria had been admitted to hospital unnecessarily. And 42% of continuing patients were non-qualified. In the Admission and Planning Unit (APU) a striking 77% of new admissions were non-qualified, and 78% of continuing days of stay were non-qualified, seriously calling the effectiveness of this model of care in the current environment into question. For General medical patients in another ward nearly half (49%) of continuing days of stay were non- qualified. In the rehabilitation wards a remarkable two thirds of continuing days of stay for patients were non-qualified. The majority of non-qualified days overall were related to “alternate care” issues emphasising the importance of explorating better options for community based care, which is a major

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Towards Outstanding Care at RHH – Newnham/Hillis theme of this current review. The MCAPs data further indicated that 14% of bed-days could have been avoided with the simple strategy of discharge home with GP follow-up.

The MCAPS data also attributes causes for non-qualified bed utilisation. For RHH 25% of non-qualified admissions were related to “consultant issues” and 59% were outside the control of the facility. For non- qualified continuing days of stay, 17% were consultant related and 20% to discharge issues. Overall 28% of non-qualified admissions and continuing days could alternatively have been provided with a variety of home-based services. A further 15% of non-qualified admissions and continuing days of stay could have been provided in supported living settings – residential aged care and assisted living centres. From this data it would seem there are massive opportunities for saving of bed days by provision of care in more appropriate environments. If RHH is to solve its current access block crisis, heeding this data to design better community-based alternatives to inpatient care is clearly required as matter of urgency. Paying attention to “consultant issues” that contribute to non-qualified bed use is also important: these included ongoing orders for routine care, not considering lower care levels, consults not done, premature admission on the pre-op day, no physical discharge plan and insufficient documentation.

Equally the University of Tasmania had undertaken an informative analysis of the processes of patient flow from the Emergency Department to Wards at the hospitals within Tasmania including RHH(18). The analysis was detailed pointing out key areas that required policy development and process re- engineering to improve the system of care. This study also noted that the APU model of care did not support patient flow to the expected extent, and was often noted to have several empty beds even whilst the ED was ramping (p33 of 53). Additionally, in the “Was the bed empty study”, (p47 of 53) destination beds were actually vacant for 49% of patients at the time of their arrival at patient triage in ED implying considerable opportunity for process improvement to reduce access block. And five wards took longer than 10 hours to admit a patient from the time of bed request even though the bed was vacant at the time of the request. Disappointingly this superbly informative data was a “one off” and is not ongoing despite its unique potential to inform the current debate around required numbers of beds versus process improvement at RHH.

RHH is a participant in the Health Round Table (HRT) initiative and performs well in some of these metrics and persistently poorly in others. However, when specifically asked about these performance measures the reviewers were informed that the clinicians had little confidence in the data sets being supplied to the Roundtable and consequently disputed the poorer outcomes. Similar comments were made about data available from Activity Based Funding or financial reports. This is disappointing as some HRT measures such as the rate of pressure injuries have been poor for a protracted length of time and are viewed by many in the health sector as ‘proxies’ for the quality of care within a health organisation.

All quality improvement activities are founded on reliable data, be the source clinical, administrative or financial. Without real time visibility and transparency of data improvement is difficult to achieve.

RECOMMENDATION 1.9

Develop capability to measure data for improvement that monitors for “bottlenecks” to patient flow (see page 22) and that has the capability to identify “qualified” and “non-qualified” patients (as per MCAPS).

Further develop and audit the accuracy of integrated reporting systems for safety, performance improvement, quality assurance and risk.

Develop a process for timely action on Health Round Table data where there are persistent ‘red flags’: currently areas of pressure care, length of procedures, use of blood, complications and day surgery activities.

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From our discussions with key staff, it appears there is no overarching IT strategy for RHH or Tasmanian Health. Procurement of new IT systems is often rushed and associate with limited assessment of the overall potential for integration with other existing systems leading to estimates that there are over 300 individual systems in the organisation being supported to some degree by a stretched IT service. Licenses for useful, advanced data analytic tools such as QlikView are limited to a relatively small number of staff.

RHH still remains dependent on hand written requests for Pathology and Medical Imaging and relies heavily on the scanning of paper medical records, both approaches prone to errors of rework, safety concerns and delay. The system cannot accommodate two clinical staff working on the same part of a patient’s digital record simultaneously, so they have to wait. We also understand that the ITS at RHH are stretched to support, let alone further develop, the hundreds of separate databases/dashboards and other platforms for quality and safety work in the organisation, the vast majority of which should instead be streamlined in an integrated EMR solution.

We believe the absence of a planned strategy for implementation of a modern EMR constitutes a significant reputational risk for RHH. Aside from an inability to deliver good decision support and to obtain extensive safety and quality data to inform improvement in care, the hospital risks the perception that it has no vision to be part of a highly performing system in a society that is relentlessly moving towards an intelligent and largely digital future. We are surprised that RHH clinical staff are not putting a stronger case for this to happen.

As with the EMR, a sound digital communication strategy for RMH that enables staff to readily communicate with various teams and people by phone, message or video, that enables virtual and impromptu group discussions, and that has approval to include patient data is a pre-requisite for a modern hospital. Many formats are available (e.g. MSTeams) and we encourage RHH to make an informed choice with a view to long term integration of all of its various systems. Such an approach would also eliminate the inefficiencies inherent in paging services.

Similarly, a simple organisational wide approach to videoconferencing between inpatient staff and services in the community (e.g. HITH, HARP, MATS see page 28 for discussion) could allow timely, stronger decision making in the community and provide virtual on-site virtual hospital specialist opinions, often avoiding the need for hospital attendance. The importance of being able to provide home based specialty opinions is one of the major recommendations for the NHS future hospital project(30).

These reviewers did not enquire into the existence of, or ease of access to, a data warehouse at RHH/THS that can provide lead clinicians with timely access to essential clinical performance data.

RECOMMENDATION 1.10

Develop a digital strategy that includes implementation of a fit for purpose electronic medical record (strategy 12 months, implementation 4 years).

Approval of new data systems should in the interim be limited to those that can be effectively integrated with the chosen service.

Evaluate electronic ordering systems for key diagnostic and service areas keeping in mind eventual requirements for integration with the EMR.

Improve communications between clinical staff both in and outside the hospital using safe technology that fosters better, safe decision making (instant messaging and videoconferencing apps).

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2. Understanding patient flow, access block and risk sharing.

We will illustrate our view of two key concepts important to improving access before discussing more specific recommendations. The first is “patient flow” and the second is the concept of “shared risk”.

Patient Flow

“Patient flow represents the ability of the healthcare system to serve patients quickly and efficiently as they move through stages of care. When the system works well, patients flow like a river, meaning that each stage is completed with minimal delay.” – Randolph W Hall, Patient Flow/Analytics magazine(31)

“Access block” typically results from poor flow of patients through a hospital and usually refers to undue queuing of patients in the Emergency Department. Despite the pervasiveness of access block in the Australian and international health care systems and a good understanding of its detrimental impact on patient outcomes, the determinants of good “patient flow” are often not well understood by clinicians or hospital leaders and flow is notoriously difficult to improve(32).

If the theory of constraints,(33) is applied to patient flow in hospitals, the most important action to improve flow becomes the identification of “constraints” or “bottlenecks” that are the rate-limiting step for the flow of patients at that particular time. Addressing the most critical bottleneck is the only way to significantly impact flow, and once addressed new bottlenecks will become apparent that likewise demand attention. Conversely, paying attention to non-bottleneck components of the patient pathway will not improve the overall flow or throughput of patients.

A simple concept to illustrate this role of constraints is to consider the use of a plastic funnel to pour petrol into a car that has run out of fuel. Assuming a mid-size funnel is used, the trick is to fill the funnel at a rate that avoids overflowing at the same time as ensuring sufficient fuel is delivered to ensure timely throughput. The rate of input, the size of the aperture, the capacity of the funnel and the size of the outlet are all determinants of flow (or mess) achieved. Progressively increasing the rate of input of petrol will eventually lead to the funnel overflowing. Interestingly, expanding the capacity of funnel will enable it to handle greater variations in input with less likelihood of spillage or under-delivery, but the overall throughput (assuming adequate delivery of petrol) can only be achieved by reducing the constraints (increasing the size) on the outflow.

Applying this concept to hospitals can help illuminate the furious debate that typically accompanies access block with regard to the capacity or number of beds available in which clinicians push for more beds whilst administrators resist and push back for greater efficiencies. In essence, increasing beds (choosing a funnel with a greater overall capacity) will have only a temporary effect on increasing the numbers of patients received into the system but will do nothing to improve the overall throughput of patients if the constraints on egress are not fully addressed. The only way to truly improve flow is to reduce constraints on the egress of patients from the hospital/ward (choose a funnel with a bigger, or multiple, outflow tract/s). Ultimately, if the rate of inflow exceeds the outflow, the system will be in access block. Likewise, applying all the effort to improve flow only to the ED when it is actually not the main bottleneck is futile in terms of improving flow and reducing access block. If bed capacity is increased without improving constraints on the egress of patients or the progression of care, the system will have more patients at any one time (waiting for something to happen) but without any improvement in flow. Costs will escalate dramatically to no purpose, a particularly unfortunate outcome when these financial resources could have been far more appropriately applied to addressing constraints on patient egress; including better services in the community to receive patients from the hospital or to avoid their admission in the first place (likely resulting in overall savings and improved quality of care, as hospitals are very risky places to spend more than the necessary amount of time).

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Figure 3: Schematic of patient flow at Alfred Health

Improving efficiencies will not necessarily improve flow. Indeed, it is essential to prioritise flow over local cost efficiencies. Sometimes this will be obvious: reducing radiology hours in order to reduce cost/CT scan is clearly poor strategy if delay in CT scans is a causative bottleneck to progression of patient care and hence patient flow. Given the estimated cost of an inpatient bed day is about $1,100, if a patient’s length of stay is prolonged by a day waiting for an essential CT scan, then the cost of that one scan is effectively increased by $1,100 and the patient’s condition may deteriorate in the interim, further increasing costs and reducing quality of care! In other cases, the cost efficiency impact on flow will be much more difficult to determine – e.g. availability of a patient’s regular team to review a patient after hours or across the weekend to progress care. The best cost efficiencies are those that both improve flow and reduce costs: perhaps reducing inappropriate ordering of scans so that important scans can be done in a timely fashion and flow and quality of care improves. Or a small increase in funding to improve the rate of bed cleans so that beds spend a higher proportion of time occupied by patients whose care can be progressed more appropriately.

Sharing of Risk

Clinicians “trade” in “risk” which must be shared equitably across the system

The second key concept that we wish to discuss for improving hospital access is the sharing of risk across a health care system. Failure to understand this concept contributes to disconnected silos of care and dysfunctional responses during times that the system is threatened by over-capacity crises, a common occurrence at RHH. We believe a “blinkered” approach which sees only the risks directly in front of a clinician and that fails to acknowledge the broader collective risk for other patients (and colleagues) across the system impairs attempts to improve flow and reduce access block at RHH.

“Every morning I have to make a decision as to whether the patient who is at least risk of self-harm/suicide in our ward is a lower or higher risk than the patients at highest risk in the ED…..because we are always full and I know I have to send one of them home….”

The above quote from a mental health psychiatrist in a metropolitan teaching hospital in Melbourne illustrates well the high clinical risk experienced on a daily basis in our health services by patients and staff. This uncomfortable risk will vary from day to day depending on patient factors such as the number who arrive in ED and the variation in rates of recovery in the ward. The mental health ward will hence

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Towards Outstanding Care at RHH – Newnham/Hillis be making tougher decisions on a day of particularly high risk compared to another when the risk is somewhat lower. In one sense the “system” has determined the level of risk at which the mental health service must operate. If the “system” were to provide 20% more beds, the situation would improve somewhat although the beds would rapidly fill. The difference would be that the ward would be able to operate at a lower level of risk for patients and staff albeit at higher cost to “system”/hospital for provision of those beds. The “system” is of course hard to define: a conglomeration of political, system managers, hospital administrators, unions and hospital staff as well as the broader community are all responsible for deciding how the system should be resourced and hence determining the level of risk at which the staff must operate.

An economist’s viewpoint of healthcare might be that the essential “currency” that clinicians “trade” in is not “dollars”, nor “numbers”, but “risk”(34). Almost every clinical decision, like that of the psychiatrist above, predominantly relates to a risk calculation of some sort – for the GP it might be “Is this patient well enough to keep at home or do they need hospital or specialist assessment”. For the ED clinician it is “Is this patient sick enough to need admission”. For the Inpatient Physician “Is this patient sick enough to need this investigation”, or “well enough to send home now?” For a healthcare system to function well this risk needs to be understood and appropriately shared amongst all players. The natural tendency for a clinician to want to work at the lowest possible level of risk for their patient, needs to be balanced with a responsibility to ensure risk is not rejected in one area at the cost of another that will then bear an unfair risk burden. In our view, “handballing” of risk is one of the main causes of tension in a hospital that disrupts flow and exacerbates access block. Typically, the ED is left catching the handball.

In this context clinicians must work within the constraints set by the “system”, essentially the “risk appetite” of the system, at the same time ensuring that the system leadership and community are well informed of the consequences of the prevailing level of risk so that adjustments can be made in a timely fashion if the risk appetite changes. Most clinicians would prefer to operate at lower levels of risk and hence there will always be a tension between the clinicians and some other parts of the “system” as to how the system should be resourced. Whatever the outcome of those deliberations there will be constraints and it is essential that resources are put to the best use to maximise safe and high-quality care and throughput/flow of patients. To quote Clayton Christensen:

“The best innovations happen in the setting of the tightest constraints” from The Innovator’s Dilemma: When New Technologies Cause Great Firms to Fail, 1997

This challenge of innovation of care despite limited resources in a high risk environment is one that confronts all participants in the system. In our view, the most productive innovations for Hobart to pursue will be substantial improvements in community-based approaches to care, where higher acuity care is possible in the community at an acceptable level of risk. If all players see that care is safely provided with risk acceptable to both the patient and the clinician, then those community resources will sustainably reduce the burden of care that currently lies largely with the hospital alone.

RECOMMENDATION 2.1

Undertake an educational project for staff designed to increase understanding of the principles of patient flow and the importance of sharing of risk across the system.

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What happens when the ‘system” is under serious access stress?

Serious access stress at RHH this would be the level 4 overcapacity protocol. The schematic diagram below (Figure 4) shows the level of risk typically tolerated in decision making when the system is under serious access stress (bed block).

Figure 4: Schematic of Risk tolerance and perception of time available for care

An ambulance paramedic “ramped” just outside the ED may be looking after a seriously unwell patient with worsening pulmonary oedema (an unknown new arrival) on the brink of death, whilst there is no ambulance to attend to a similar patient in the community (unknown, unarrived). In the ED, the staff may be struggling to work out who is the least risk patient to shift out of a resuscitation cubicle to accommodate a known new, seriously unwell and deteriorating patient whilst other staff are desperately trying to see new patients in the corridor simultaneously with attending to the equivalent of a ward full of admitted patients, some of whom are also sick and perhaps waiting for an ICU bed. Meanwhile, patients in the ED waiting room are getting increasingly anxious about the many hours delay to be seen, and some are clinically deteriorating.

Up in the ward the staff may receive an alert from ED or the flow manager indicating the situation is overcapacity. However, perhaps as a result of alert fatigue and perhaps because they already believe they are doing all they can, they may not perceive the same sense of pressure or urgency as the ED. The ward docs know they are looking after 10 or more patients who are waiting to go to a subacute bed and are exasperated that if the system was really in crisis “something should be done” to help those patients move. Staff in the ICU are frustrated because they can’t take new seriously ill patients from the ED to their ward because there is nowhere for their existing patients who no longer need their services to move to.

In the subacute ward the atmosphere is a further step lower in terms of the sense of risk or crisis that is carried in the ward. These subacute staff are similarly frustrated that the meagre post-hospital community care services are unable to accommodate the dozen or more patients that have been otherwise ready for discharge for the last week or two…..

In summary there is access block throughout the system, patients at risk, person-centred care is disrupted and staff everywhere are frustrated.

When we asked staff across the system at RHH whether they believed there were some patients in the community who were at higher risk of poor outcomes than the patients in subacute or acute they usually agreed. Although they may not have recently been involved with the care of a patient in a sub-acute ward, the ED staff universally agreed with the scenario that if patients from the subacute ward were transferred to the ED, a significant proportion would be sent home rather than continuing to be cared for in an inpatient bed.

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Why are risk and urgency not equally shared across the system?

Most clinicians want to provide the best care for the patient in front of them. Typically, this includes minimising the risk for that patient. It is not surprising that doctors who do not understand the imperative to share risk primarily work to minimise the risk for the patients they know well, “their patients”, not recognising that to do so exclusive of the broader community of patients is compounding a horrendous risk for the patients and their colleagues who are in ED or on the ambulance ramp.

When we reflect on the discussion regarding risk (see mental health example quoted above), the message that is really being sent at the time of an overcapacity distress alert is:

“Our risk is much higher today than usual. Decisions that you may have made yesterday may no longer be appropriate in the context of the risk we are experiencing today. The appropriate decision to defer discharge or accept a delay in progression of care yesterday does not cut it today…we need to work differently and to a higher level of risk. If we do not do so we are transferring intolerable risk to our patients and colleagues in the ED or on the ambulance ramp and we are jointly accountable for those patients’ outcomes”.

No-one wants to work in the circumstance reflected by this quote. But this unwelcome message must be heeded regardless of the current perceived efficiency of care at any particular site or time. Unfortunately, overcapacity crises are very frequent occurrences at RHH and current change management processes have not successfully addressed them, albeit acknowledging the current infrastructure constraints on the system.

The other chart incorporated in Figure 4 (see line) refers to the “perceived time available for care”. All the RHH staff we asked agreed that, in the ED, performance is measured in minutes or hours, in the acute ward performance is measured in hours to days and in subacute ward often in days to weeks. All staff also agreed that if a patient discharge is delayed from subacute – perhaps the tradesman can’t install a ramp on some steps to allow the elderly patient with poor mobility safe portal with their newly acquired 4-wheely frame until next week – that delay then means another patient waits in an acute bed for that subacute bed and similarly an admitted patient is stuck in ED being unable to go to the acute ward. If there is access block, a patient may be sitting in a ramped ambulance unable to receive required medical care! Given this obvious scenario of cascading consequences of delayed discharge from subacute back to the ED with progressively increasing risk, why is this difference in the sense of urgency or perceived time available for care tolerated? Whilst it makes sense for non-admitted patients in the ED to be prioritised in terms of progression of care in the setting that the rate of their progression of care is the obvious bottleneck (as there is no constraint on egress), the same is not true for admitted patients. Progression of care for all admitted patients is helpful but it is most important where it constitutes a critical bottleneck. Any saving of bed days at sites for which there are patients waiting for a bed in acute or subacute will improve flow. The most important bed days to save are those where the most critical bottleneck exists, which may vary from unit to unit and amongst different patient groups. For RHH our impression is that the wait for subacute care including aged care, rehabilitation and palliative care constitute a particularly critical bottleneck for flow for patients requiring those services; a large number of bed days are currently used for unqualified patients in this group. On the other hand, for patients not requiring subacute care, it is the processes of progression of care itself that need to be examined for the most important bottlenecks as by definition these patients will be returning directly home.

The above discussion has considered flow largely with the analogy of a single funnel. It is more useful to consider patient flow from the perspective of patients moving through many sequential or alternative funnels. From the staff and management point of view, almost every service, ward, department or unit could be considered as a funnel with the leaders and staff collectively charged with continually improving flow through their patch with the ultimate aim of improving flow across the entire service. In each case, the ingress of patients, timeliness of progression of care, capacity, constraints and outlet/s all need to be continuously monitored and improved to maintain the best possible patient flow. Inevitably the non-bottleneck areas will need some redundancy and extra capacity because of the importance of maintaining the best possible flow through the most difficult bottlenecks at all times and because there will always be some variation in demand over time.

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Returning to our earlier discussion regarding the need for a clear goal for healthcare in Hobart, we here re-emphasise the fundamental importance of investing to develop strong improvement capability to achieve effective patient flow. Our proposed goal from the clinical viewpoint is restated and we now added an extension from the financial (cost) perspective as well as a figure to illustrate the importance of investing to improve flow from both the patient and staff viewpoint:

The goal is to provide the best, person-centred care whilst utilising the minimum required hospital capacity so that the limited resources are used to improve flow, patient outcomes and patient and staff experience.

…..from the cost perspective it is important to avoid wasting resources in the provision of oversized, staffed areas for patients merely to wait for the next step in their journey!

Figure 5: Investing in improvement from business and staff perspective

3. Improving flow to improve patient access

Timely progression of care across the whole health system is essential to improve patient outcomes, access to care as well as patient and staff satisfaction.

Having considered the concepts of flow and shared risk above we will now discuss recommendations to improve flow and access at RHH. We will consider in turn:

Non-admitted patients attending the ED Acute admitted patients attending the ED discharged from The Emergency Medical Unit (EMU), short stay unit The wards (focussing on General Medical services as a case study). Subacute Care Elective surgery/procedural patients Mental health patients

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Non-admitted patients attending the ED

“We are now practicing a different sort of medicine….. Corridor medicine, ramp medicine, waiting room medicine. We can go for weeks examining every patient in the corridor because the cubicles are always full with admitted patients. ….but the inpatient teams keep holding us to a pristine standard (as if we are operating in a properly functioning ward environment). Their view is that the ‘ED can’t cope.’” - Frustrated ED consultant at RHH

Non-admitted patients are those patients who attend the Emergency Department and leave without admission to an overnight bed. At RHH ED they constitute the vast bulk of presentations to the department. Approximately 62% of the 64,000 presentations to the ED each year are discharged directly from the department. Since July 2018 only about half of these patients who are not being admitted to hospital leave the department within 4 hours (52.1% to April 2019). There is a high likelihood that further improving the timely management of these patients would improve access block.

The “funnel” for non-admitted patients is different to that for much of the rest of the hospital. These patients have few barriers to egress from the hospital other than the rate of progression of their care during their stay i.e. the funnel has a large outflow tract. The main constraints/barriers to good flow for this non-admitted patient group include firstly the marked variation over time in the numbers of patients entering a funnel which has a relatively large “aperture” facing the outside world but limited internal capacity and secondly, anything that delays progression of care for these patients.

Walk-ins from the community, ambulance arrivals, inter-hospital transfers, readmissions and referrals from primary care, consulting clinics and specialists all need to be accommodated in the only public ED in the whole of Hobart. Because it is the only public ED in town the RHH ED has to cope with “all comers” regardless of whether the rate of presentation is orderly and smooth or in batches of extreme demand interspersed with relative periods of quietude.

As the above quote suggests, the available 32 spaces in ED are almost always occupied by admitted patients awaiting an inpatient bed and hence the department is essentially acting as “pipe” with little or no available capacity making the provision of quality and timely care extremely challenging and forcing it to occur in a very suboptimal “corridor” environment. Corridor consultations are not patient-centred, they are inefficient and time consuming and constitute high-risk care. To function well despite these serious constraints requires maximum attention to all possible avenues for improvement, the vast majority of which have been recommended in previous reviews (see Appendix 2).

The authors believe that, for an ED to have excellent access performance the target for 4h turnaround of non-admitted patients should be in the vicinity of 95%. A reduction of ED length of stay by just 1 hour from 4 to 3 hours in an ED experiencing 10 arrivals per hour, results in a 25% reduction in the number of patients in the ED at any one time and a 2h reduction leads to a 50% drop in occupancy(35). Given the current pressures on the RHH ED it remains essential to aim for such a target, however difficult it is to achieve. We believe this reduction of length of stay is more achievable in the short term for non- admitted rather than admitted patients, although both are important. Whilst many of the items listed below might be happening to some extent, the feedback from staff is that the practices/services are not optimal.

Reducing patient presentations to RHH ED

Given the current access crisis and infrastructure limitations, actions that can reduce patient presentations to the ED of RHH should be a major priority (i.e. smaller input into a limited capacity funnel) and will be discussed from the perspective of community based alternatives, ambulance transfers, inter-hospital transfers (including private hospitals) and the role of ambulatory care clinics.

Community-based alternatives to ED attendance or patient admission There is already some work started to encourage patient attendance to local primary care services rather than attending the ED. The DoH should continue to enhance the viability of these services and their hours of availability and should work to reduce the likelihood of locum services channelling patients

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Towards Outstanding Care at RHH – Newnham/Hillis to the ED when there are more appropriate options for their care. Despite the superficial attractiveness of co-located or hospital-run primary care services the literature does not support going down this path in the context of the currently limited primary care resources in Hobart and the tight space constraints in the RHH ED.

Like many Metropolitan mainland healthcare services, RHH has relatively limited capacity to extend its care to the community despite the large numbers of non-qualified patients who are in the hospital but could be cared for elsewhere (see MCAPS 2017 data discussion page 19). Examples of such services in Victoria include the Mobile Assessment and Treatment Service, (MATS), at The Alfred Hospital, which sends a geriatrician or advanced trainee registrar and geriatric nurse to provide diagnostic and treatment services when requested by a nursing home or the patient’s GP. MATS also provides prompt review and ongoing support to return patients to their usual residential accommodation at the earliest opportunity after ED attendance or following hospital discharge. For patients living independently, a somewhat similar service known as Better@Home at Alfred Health provides geriatrician, nursing and allied health support in the home, again after referral from their GP or following hospital discharge. In addition, the Hospital Admission Reduction Program (HARP) in Victoria provides very experienced nursing support akin to the ComRRS program in Hobart although in some centres it also has ready access to hospital specialists opinions including medical visits into the community. The Dutch Buurtzorg nursing model is another good example of effective team-based nursing in the community(36).

Most Victorian hospitals have a very well developed Hospital-in-the-Home, (HITH), program capable of handling considerable complexity even in some cases to the extent of providing inotropic support at home for cardiac patients and caring for those with Ventricular Assist Devices (VADs). In some hospitals up to 15% of patients receive inpatient substitution with HITH. These services all aim to work together to minimise the risk of patients “falling between the cracks”.

The effectiveness of services such as MATS requires strong engagement with nursing homes, GPs, patients and their families. Good relationships can foster timely utilisation of MATS services to minimise hospital bed utilisation and encourage the establishment of KPIs regarding advanced care plan completion and adherence so there is clear understanding whether or not patients desire transfer to hospital in the event of acute deterioration. Early telephone contact with the MATS nurse or registrar often allows rapid on-site intervention to the benefit of patient and family and minimises ED attendance. If the patient does attend the hospital this service also facilitates timely return as soon as their clinical condition permits.

Given the challenges of scale in Hobart, rather than emulating each of these services, it would make sense to develop a single flexible coordinated service to meet the vast majority of the care provided. Such a service could adapt the care it delivers to the needs of the patient, calling in more “specialised” resources as required. It should have access to opinion from both General Practice clinicians as well as hospital specialists by telephone, video or where possible, in-person consultation on-site.

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RECOMMENDATION 3.1

The DoH should work with nearby primary care and locum organisations to enhance, publicise and refer patients to them as an alternative to ED attendance 24/7.

Identify and bring together thought leaders in the hospital and community who can participate in designing and extending outreach and community-based services to meet the health needs of all of Hobart (including mental health).

Improve access to outreach/care coordination and other community-based services especially for patients in residential care and patients in their own private residences with frailty or multiple complex chronic disease.

Develop a single coordinated unit working between the hospital and community to progress programs that reduce patient presentations and can deliver specialised nursing services and hospital specialty opinions in the community

Develop sustainable funding models for the above proposals to incentivise hospitals to use them.

Implement suitable models of care to facilitate provision of hospital-based advice and specialty opinions to support nursing or medical staff visiting patients outside the hospital (including user friendly videoconferencing).

Foster discussions with residential aged care services regarding advanced care plan completion and adherence so there is clear understanding whether or not patients desire transfer to hospital in the event of acute deterioration.

For Mental Health patients, resource CAT and other community-based MH teams to provide timely and ongoing care in the community supported by MH consultant opinion (e.g. videoconference) to minimise transfers to the ED for patients at risk of a crisis.

It is appropriate to note that the funding model in Victoria supports the aforementioned services to a considerable degree. For example, HITH patients in Victoria mostly receive 80% of the inpatient Weighted Inlier Estimated Separation (WIES) value, whilst Better@Home is funded by Subacute WIES (SWIES). In recent years Victoria has developed a pooled funding model known as HealthLinks to incentivise hospitals to use funds that would formerly have funded an inpatient admission to instead support community-based ambulatory services to help keep patients out of hospital.

Ambulance assessment, treatment and transport “Currently obligated to send ambulance - cultural imperative. Ambulance should decide whether an ambulance will be sent and whether or not the patient requires transport”. - Ambulance Tasmania staff member.

In our meetings with Ambulance Tasmania (AT) representatives it was clear that work has already commenced on increasing secondary triage approaches aimed at encouraging diversion of patients contacting (AT) to more appropriate care options that do not require transport to the ED. The reviewers acknowledge the work already undertaken on the enhanced paramedical role by AT. Interestingly the HRC UT study(18) indicated that a large proportion of ambulance arrivals were stable enough to be offloaded into the waiting room and that half of all patients that arrived by ambulance were discharged directly from the ED or chose not to wait for treatment, implying a low level of acuity/complexity of care in this patient group. The policy of free provision of ambulance services in Tasmania appears to be associated with higher ambulance activity per head of population and higher transfer rates to hospital as compared with states who do not have this policy.

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“The front door of the hospital should be moved to the back door of the ambulance. The patient has entered the health care system at the time of the call to the ambulance ….this should be reflected in the approach to ramping”.

- Ambulance Tasmania staff member

There is ongoing discussion between the Emergency Department at RHH and the Ambulance Tasmania. Issues of ambulance ramping and the emergency department overcapacity protocol require further negotiation between both parties. These reviewers favour the patient becoming the responsibility of the hospital from the time the ambulance officers notify the hospital that they have parked at the ED ramp, because of the potential serious but unknown risk of deteriorating patients in the community.

RECOMMENDATION 3.2

Reduce ambulance arrivals:

Continue work on secondary triage to deliver care at appropriate community resources rather than in the ED.

Understand the processes that link patient transport to ambulance attendance to ensure that transport to the ED is only required when clinically indicated and only after other appropriate options for client management are found to be unavailable.

Work to change community perceptions regarding ambulance utilisation.

Review the overcapacity protocol to consider patients whose arrival has been notified by ambulance services to the ED to be the responsibility of the hospital.

Relationships with other hospitals RHH hospital receives many transfers of patients from other hospitals that do not have the capacity or capability for their care. In order to provide this function in a timely manner it is essential that these transfers are made in an agreed, transparent fashion. A senior clinician (usually consultant) of the appropriate receiving inpatient unit should be fully informed prior to the transfer commencing and accept care of the patient directly into their ward bypassing the ED unless the patient is unstable and requires ICU or ED attention. In addition, the referring unit/hospital should unconditionally accept return of that patient as soon as the RHH team deem it clinically appropriate, consistent with our earlier comments regarding “sharing of risk” across the system.

The private hospital system in Hobart has significant ED capability as well as inpatient capacity. Our discussions with Ambulance Tasmania services indicated that private hospitals are often reluctant to accept ambulance transfers to their ED with those patients defaulting to RHH. In addition, there do not seem to be clear protocols for enabling timely transfer of insured patients to private hospital inpatient beds when that is both acceptable to the patient and clinically appropriate. The forthcoming contract renewal with Hobart Private Hospital provides a very timely opportunity for the DoH to negotiate a more effective acceptance process with that private service. The DoH/THS should use their role in system oversight and management to work with private services to come to an agreed city-wide approach to periods of access stress and to expand negotiated public use of private inpatient capacity as much as possible until RHH access stress resumes sustainable levels. These reviewers see no reason why private hospitals should not be expected by the system leaders to contribute to the sharing of access risk across the system, at least for compensable patients who wish to be treated privately.

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RECOMMENDATION 3.3

Inter-hospital patient transfers: Develop an agreed inter-hospital transfer policy that clearly identifies responsibilities of the receiving and transferring units/hospitals regarding acceptance and timely return of patients.

Private hospitals: The DoH/THS should use their role in system oversight and management to work with private services to come to an agreed city-wide approach to periods of access stress and to expand negotiated public use of private inpatient capacity as much as possible until RHH access block persistently resolves.

Ambulatory care clinics RHH ambulatory care clinics provide many patient services. An important role for such services in Hobart should be to contribute to the minimisation of access block. It is therefore essential that ambulatory clinics manage their workload and case-mix so that they can also provide timely access for acute patients who can have their care in clinics or as day procedures rather than defaulting to the ED. Monitoring the performance of ambulatory clinics and streamlining services to improve access and efficiency requires dedicated process improvement work and an ability to seek agreement across services and silos of care. In many hospitals this ambulatory activity is considered of sufficient import to prompt the establishment of a hospital-wide ambulatory clinical service stream similar to those of acute inpatient service streams led by a senior medical and nursing duo. In addition, occasional audits of numbers of patients presenting to the ED who should have been managed in ambulatory/day services should be conducted to identify opportunities for improvement. In particular, RHH should have processes in place to deter elective patients “jumping the queue” for hospital admission by presenting instead to the ED at the encouragement of their treating surgeon/physician.

RECOMMENDATION 3.4

3.4.1 Ensure Ambulatory care services receive appropriate representation and improvement focus at hospital executive level meetings so that clinics provide timely access for referrals from the community and help relieve hospital access block.

Improving the progression of care for “non-admitted” patients in the ED

Having discussed strategies to reduce the number of patients attending the ED, we will now focus on improving flow and access block by concentrating on improving the progression of care of patients who have arrived at the ED.

The ED staff repeatedly voice the difficulties in seeing patients during times of access block because “admitted” patients occupy all the cubicle spaces. Relieving the bottlenecks and barriers to flow that cause these patients to spend many hours in the ED will unfortunately take some time. In the interim it remains imperative that RHH non-admitted patient performance approaches the 95% target despite this constraint for reasons previously discussed. Pending further planned formal redevelopment of the ED, additional space to see non-admitted patients is required urgently and could include a reassessment of the footprint devoted to the Admission and Planning Unit (APU) ward and EMU on the same floor as the ED.

Reducing time from patient registration in the waiting room to commencement of care in an ED space can be aided by having only a minimum clerical data set commenced at initial registration with the patient being subsequently revisited by the clerk in the cubicle area to finish clerking after the patient’s care has been commenced. Reducing the time in triage in favour of earlier commencement of care in an initial assessment in the cubicle or fast track area can also improve progression of care. The aim of

32 Towards Outstanding Care at RHH – Newnham/Hillis triage should be to “point the patient safely and immediately to the right area for provision of care” rather than to decide “how long they can safely wait”. As much as possible the patient should enter the ED directly from triage to commence care with an experienced clinical decision maker without returning to the waiting room at least until care has been initiated.

“Triage is sometimes considered to be the use of an experienced nurse’s time to inform someone of how long they can safely wait for care. Much better to place the patient as soon as possible in front of a clinician who will take responsibility for initiating and progressing their care.” – experienced ED clinician

The role of ED consultant staff has traditionally been very focussed on the supervision of trainees. Whilst this supervision is a critical component of training there is an imperative at RHH in the current climate of persistent critical access risk for the patients to be seen initially by an experienced staff member to assess and rapidly progress patient care in order to maximise capacity and throughput(24). This particularly applies to frequent and complex attenders to the ED who can be most rapidly dealt with by an experienced clinician but may take junior staff considerable time to assess and then await more senior approval of the care plan.

The timely opinion of an experienced inpatient clinician is an important resource to improve the care the ED team provide. An inpatient clinician who knows the patient or the problem well will be best placed to decide on the appropriate next steps with minimum delay and avoidance of unnecessary investigation and should be able to facilitate urgent clinic follow-up if required. Although true for most specialties this is probably of most importance for complex elderly or patients with multiple comorbidities for whom ED assistance in the form of timely provision of geriatric or general medicine expertise can avoid considerable delays and build relationships between the ED and community aged care providers. This will also foster effective use of the admission avoidance pathways discussed above. These reviewers believe that this use of geriatric clinician time is likely to be of greater benefit to inpatient flow than the current time spent supporting a specialised inpatient geriatric ward.

It is not uncommon for ambulatory care responsibilities to contribute to delays with busy JMOs opting to “review the ED patient after the clinic”. RHH clinical leadership should ensure all clinicians understand the primary importance of prioritising activities that will improve inpatient flow. Unit heads should control ambulatory workloads to ensure relevant JMO staff are able to provide timely support for the ED staff at all times. These response times of inpatient clinicians should be monitored and reported to clinical stream heads to identify opportunities for improvement.

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RECOMMENDATION 3.5

Increase available spaces in the ED and re-model care to support reduction of the transit time for non-admitted patients and create a high performance 4h KPI for this non-admitted patient group.

Minimise triage time and detail to facilitate rapid streaming of patients to a senior clinical decision maker who will commence their care in the most appropriate space.

Collect only a minimum data set at initial patient registration in ED, completing the collection once a patient’s care has been initiated.

Implement and monitor performance of the previously agreed “Timely Quality Care” principles including ED consultant authority to admit the patient on interim orders without prior unit review.

Establish an agreed escalation protocol for unacceptable delays by inpatient staff responding to requests for opinion or notification of admissions by the ED staff. Measure these delays in order to identify the most important opportunities for improvement.

Implement systems where JMO availability to respond when referred patients by the ED is maintained even in the setting of clinic, theatre and ward rounding responsibilities.

Schedule daily consultant geriatrician rounds through ED and EMU to facilitate admission diversion plans for complex elderly patients and upskill ED staff on alternative pathways of care.

Improving access and flow for Admitted patients

How could access and flow be improved for the admitted patient group at RHH ED who have potential for direct discharge from the acute ward rather than likelihood of subacute admission or new requirement for residential aged care? This is again a group with, by definition, no major impediment to egress from the hospital so that the rate of their progression of care becomes the main determinant of throughput or flow.

Patients admitted to the EMU (Emergency Medical Unit)

The highest activity admitted patient group at RHH (7,216 patients per year or 31% of all admitted patients) is those patients admitted to EMU. The agreed KPI is that >85% of these patients will be discharged directly from the EMU without admission to another inpatient ward within 24 hours of presentation. We note that at the time of the HRC UT study(18), EMU had good performance on that measure and an acceptable LOS of 11 hours but only 62-69% occupancy which suggests room for better utilisation. Typically, EMU patients are those patients that require more than a 4 hour period of recovery/observation/response to treatment before being discharged. Although classified as admitted patients their care is provided solely by the ED team and does not usually involve inpatient teams unless there is an opinion requested regarding admission to an inpatient ward.

This group has been extensively considered in prior reviews(18) and will not be considered in detail here as almost all the above recommendations for non-admitted patients apply equally to the improvement of flow within this group. Nevertheless, there are a few special points to be highlighted. Because these patients in the EMU constitute such a large number of overall bed days in the organisation it is important that an experienced ED consultant has sufficient and regular oversight of the progression of their care and that junior staff are empowered to discharge patients from EMU based on criteria agreed with the supervising consultant. Similarly, experienced allied health staff provide an important means to oversee safety of discharge but also to stimulate exploration of alternative pathways of care for groups of patients that are often challenging for busy medical clinicians to assess. A missed opportunity to divert a complex elderly patient to a more appropriate non-admission pathway in the community is an

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Towards Outstanding Care at RHH – Newnham/Hillis expensive error for an organisation that has serious access issues. The aim in EMU should be to have safe, rapid progression of care so that EMU beds can be utilised by as many patients per day as possible. Ideally the ALOS in EMU should be about 8-9h allowing two or more patients to benefit from each bed in its service in every 24-hour period.

Patients who do not fit the model for EMU care should not be admitted there as doing so will effectively shrink the capacity of the funnel for good patient flow through EMU and ultimately exacerbate access block.

Leadership should regularly model whether the bed number in EMU (currently 16 beds) is optimal to improve flow and care. If modelling indicates that increasing the number of EMU beds would improve flow, then this should be a priority. Initial measures could replace some AMU beds with EMU beds, provided the net effect is to enhance patient flow through the organisation as a whole.

RECOMMENDATION 3.6

RHH and ED management should review annually:

Allied health resourcing and level of experience to ensure best possible, timely decision making for the ED and the EMU.

Modelling of EMU bed numbers and usage to ensure they are optimally improving overall organisational flow.

Staff orientation/education to ensure all staff have a working knowledge of available admission diversion models and referral pathways.

Patients admitted to and discharged directly from the acute ward

The two major priorities to influence the flow of patients admitted to and discharged from the wards at RHH are firstly, ensuring admission of only appropriate (qualified) patients (which has already been discussed in some detail on page 19), and secondly, the timely progression of care. The major difference between ward and ED/EMU progression of patient care follows from our early discussions regarding “risk” and “perception of time available for care” as illustrated in Figure 4. During the shift to the EMU the ED doctors retain responsibility for care and there should be no substantial barriers to be overcome with all ED/EMU staff continuing to work in the same ED “minutes and hours” mindset, although we note the UTAS_HRC study(18) did recognise undue delays in this process during their review. In contrast, when shifting from the ED (or EMU) to the ward, there is a very frequent bottleneck that delays progression of care. Inpatient staff working in the ward context may have many competing priorities for their time and often “push back” against the ED requesting further investigation of a patient’s condition before “acceptance” of the patient or declining acceptance in favour of admitting the patient to an alternative service or team. One justification for this “push back” by inpatient staff is that they know their patients will have to wait longer for the same tests to be done should the patient reach the ward before they have been completed, because the patient “loses their place in the queue” for that investigation. It is a common practice in many hospitals for a busy registrar to order an additional investigation to keep the patient in the ED a little longer, where they perceive them to be safe, in order to reduce the urgency for they themselves to clerk the patient. Sometimes it might be done in order to develop a stronger case for the patient to be admitted to an alternative, more appropriate team. Indeed, for a stressed inpatient registrar, “pushback” may be the easiest immediate approach to manage an excessive workload and their own perception of risk.

“All organisations are perfectly designed to get the results they are now getting. If we want different results, we must change the way we do things.” – Tom Northup

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In essence the system is perfectly designed to deliver the result it is delivering, which in the event of “pushback” will be to disrupt patient flow due to delays in progression of care and hence to worsen access block. This situation is particularly likely to arise when the inpatient team do not understand determinants of flow and sharing of risk discussed earlier; their understandable goal will be to minimise the perceived risk they have to deal with for the patients for whom they are immediately responsible.

Re-designing care to avoid pushback involves establishing trust and agreement between services and breaking down the barriers between silos of care, improved staff education, appropriate rostering and resourcing to meet key periods of patient demand and agreed prioritising of tasks towards those most likely to lead to timely progression of care. This is especially important where that care is at least a partial bottleneck with patients being unable to leave the ED because they have not been “accepted” by the inpatient registrar. The aim is to address all the contributors to “pushback” and replace them with a culture of the ward teams proactively “pulling” patients from ED.

In some cases, it may be the ED staff themselves who are reluctant to send a patient to the ward despite access issues in the ED. Overnight or on weekends for example, if the ED staff perceive that ward staff are under pressure, too junior or under-supported, they may conclude that the ward is not a safe place, and delay transfer of a patient to the ward until (Monday) morning, further contributing to access block. Many Australian metropolitan hospitals have instituted task and teamwork-based practices after hours to achieve a safe “hospital-at-night” program to both placate these concerns regarding safety and to allow progression of patient care overnight.

RECOMMENDATION 3.7

Review and redesign consultant and JMO staffing and rosters to facilitate progression of patient care in and out of hours and across weekends and ensure a realistic workload with minimum overtime.

Establish agreed protocols (minimum order sets) for the most common clinical reasons for admission between the ED and inpatient teams so that all have confidence all necessary tests will be initiated in the ED and completed in a timely manner regardless of when the patient is transferred to the ward.

For patients in the ward, set tight, transparent KPIs to minimise delays between ordering and completion of investigations and referrals found to be most important to the progression of care so that staff are confident they will occur in a timely manner even after the patient has left the ED.

Before considering specific services or units, we would like to make some observations about more general measures that could enhance both patient safety and flow for patients admitted to the wards of RHH – most of which have been recommended in previous reviews but are not still fully actioned.

Quote: “Flow needs to have more strength” – RHH senior clinician

We have already emphasised the importance of a robust “Daily Operating System” in which experienced staff responsible for patient flow communicate frequently with lead clinicians and operations management regarding patient flow and bed management throughout the day. All participants should have ready access to real time data regarding the bed state and projections for the hospital. RHH already has the IOC system to assist this approach.

Strong bed management data systems are crucial for the co-location of patients in the right bed spaces to facilitate effective interdisciplinary teamwork and to minimise “outlier” patients, a group that have repeatedly been shown to suffer high risk and delayed progression of care. It is extremely difficult to properly involve bedside nursing staff in the daily interdisciplinary team discussions necessary to achieve timely and person-centred progression of care unless there is a high degree of co-location of patients with their team’s base. RHH should focus on achieving correct patient geography particularly

36 Towards Outstanding Care at RHH – Newnham/Hillis for its busiest services – General Medicine, General surgery, orthopaedics etc. so that they can function at their highest efficiency.

We believe that this strict geographical approach is one of the fundamental factors contributing to the effective interdisciplinary team-based care often described in the literature for new models of care such as stroke units and acute medical units. For General Medical patients, combining the AMU and General Medical patients into a single co-located service that aimed to offer all the purported advantages of the APU to the whole group would allow a simpler, single general medical service. We also noted the UTas_HRC(18) reported concerns regarding the failure of the APU to meet expectations regarding patient flow at least some of which still seem current. Routinely reported, transparent data indicating the percentage of each team’s patients who are in the correct geography should be monitored to inform improvement work.

RHH already aims to use a “flex” bed model designed to cope with times of increased demand. These beds however, tend to be in a state of more or less permanent use negating the value of the model. As soon as capacity provides the opportunity it will be important to re-establish an effective “admission bed” model. These admission flex beds should be staffed for only a single nursing shift during predicted, daily periods of expected demand to accommodate the egress of admitted patients from the ED. They should be situated in appropriate destination wards under the management of the nurse manager who is also responsible for achieving the correct geography for these patients when they move from these flex beds to their overnight bed. For example, four beds may open during 1-8pm in a ward that tends to have high demand for admissions from the ED (e.g. General Medicine) during this period allowing immediate transfer from the ED to the correct ward with a time imperative for the nurse manager to have the admission beds closed by the end of that shift. In this way the organisation has increased flex capacity at the times of most predictable demand that can be met by staffing for a single shift rather than across 24h. As with EMU, protecting the integrity of this model is essential to realising its function.

“There are two categories of cleaners, regular bed and isolation cleaners. Union issues….. Beds can go two shifts waiting for an isolation bed clean. We need a process for a cleaner to register they have finished cleaning a bed.” “We need to be able to prioritise bed cleans to meet flow imperative” – RHH nursing staff responsible for flow.

In our discussions with staff responsible for flow and bed management it was clear that there is an opportunity to improve the ward “pull” culture by reducing the excessive time currently required for “turnover” of beds. A significant bottleneck appears to be in the cleaning of the bed and space especially for “isolation” cleans, the latter sometimes taking whole shifts to eventuate. In discussion with other Australian hospitals it is apparent that some have managed to reliably achieve 15 minutes for routine cleans and 1 h for isolation cleans – RHH should urgently review bed and room cleaning practices to achieve these targets. This should involve better coordination of cleaning staff across the hospital to actively involve them in contributing to patient flow KPIs. It is especially important to have a reliable process for cleaners to report immediately that they have completed a clean to the relevant personnel responsible for patient flow.

“The Paris risk screening tool is not being utilised in 60% of the hospital” - Hospital staff member seriously concerned about quality of care

From our discussions with staff it is evident that the “Paris” patient risk screening tool that is designed to minimise the risk of hospital-acquired complications is not consistently utilised across the organisation. These tools are an important contributor to safety and quality of care and hospital acquired complications clearly impact on patient length of stay, flow and access block. The consistent use of an effective risk screening tool should be a high priority for RHH and will be important for the forthcoming “SNAP” hospital accreditation process.

Effective integration of pharmacy expertise with hospital medical teams has shown to improve safety and quality of care(37). Medication errors are one of the comments patient risks in our hospitals and are

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Towards Outstanding Care at RHH – Newnham/Hillis frequently under-reported. There is an opportunity for RHH to further minimise medication errors by developing closer integration of pharmacists with interdisciplinary team care at RHH. One example of this is the “Partnered Pharmacist Charting” work that is currently being scaled up in Victorian hospitals and is funded by Safer Care Victoria. This approach has clerking registrars partnering with pharmacists at the time of patient admission to achieve a high degree of accuracy in prescribing with virtual elimination of common errors(37). One author of this report (HN), acknowledges a conflict of interest, as he is a contributor to this work. Effective integration of pharmacists in routine ward-rounding also has potential to promote effective de-prescribing of high risk or unnecessary medications during hospital admissions and outpatient attendances further reducing potential complications of polypharmacy and low evidence-based care(38).

“The (large specialty) unit only manages to complete 50% of discharge summaries within 48h of discharge”

We have mentioned only briefly the importance of improving the safety and quality of care to improve patient access. Effective discharge planning is a major contributor to reducing length of stay and improving patient flow. Having good systems in place to predict and plan for the day of discharge is fundamental to achieving patient outcomes and this should of course be a major focus of all inpatient services. One indicator of the health of this process is the timeliness of completion of discharge summaries. Data from RHH indicates significant scope to improve this indicator with the aim of improving patient outcomes but also reducing the likelihood of readmission and hence access block.

The use of ward rounding checklists has potential to improve safety and quality of care as well as keeping discharge planning at “front of mind”(39). Including in the checklist information regarding the ongoing need for intravenous lines, urinary catheters, prompts for review of Goals of Care (resuscitation plans) and a statement regarding estimated discharge date and barriers to discharge can make checklists a simple but potentially highly effective tool to improve progression of care and patient flow.

As part of Good Ward Governance, regular 4pm board meeting in all wards attended by medical, nursing and pharmacy staff is a good way to ensure barriers for early discharge the next day are addressed well in advance (e.g. waiting for scripts, discharge summaries or transport).

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RECOMMENDATION 3.8

Ensure the IOC acts to connect relevant staff and oversee effective patient flow across the system.

Monitor and routinely report on “right patient, right bed”; the percentage of patients in each team’s correct geography to encourage colocation of patients in the correct beds, minimise outliers, and foster interdisciplinary teamwork.

Develop a process to achieve tight KPIs for bed “turnaround” times, especially isolation cleans.

When there is capacity, the IOC should further develop an admission flex bed model in which beds staffed for a single nursing shift are opened at predicted times of peak demand for egress from the ED. These beds should be available in the most likely destination ward to improve correct geography.

Ensure consistent use of the ‘Paris’ patient risk screening tool or similar at RHH.

Increase the integration of pharmacists with interdisciplinary team care at RHH to improve reporting, and reduce occurrence of medication errors and foster effective de-prescribing practices.

Improve the timely provision of discharge summaries to GPs and other specialists to improve quality of discharge planning and minimise the risk of readmission.

Develop ward rounding checklists that include safety and quality items (status of intravenous lines, urinary catheters, goals of care and estimated date of discharge) for use in daily morning ward rounds.

Institute ward-based afternoon board rounds (e.g. 4 pm) with medical and nursing decision makers to plan all aspects of early discharges the following morning.

Patients admitted to the ward who require inpatient subacute care, rehabilitation or limited community-based services.

Patients who are admitted to the ward at RHH and are destined to be transferred to subacute care not only traverse all the aforementioned barriers to progression of care but also, by definition, meet probably the most troublesome bottleneck to patient flow in the entire organisation. This is the difficulty in, and delay in access to, subacute care including aged care services, rehabilitation and transitional care and other necessary services required before they can safely return to their home or residential facility in the community. As a result of this bottleneck their acute inpatient beds, that could be best used to progress timely care for complex acute patients, are not available and instead admitted patients queue for access in the emergency department, contributing to access block with all its attendant risks and stressors in the ED.

Returning to the funnel concept of flow, good access to subacute care requires appropriate entry of properly selected patients, timely progression of their care, sufficient minimum capacity and staffing to do the work and cope with variations in demand and finally, a safe timely egress of patients to the community.

Selection of patients for subacute care at RHH by consultant or JMO staff is almost always “vetted” in person by the subacute staff receiving the referral before the transfer is activated. The referral processes are complex for acute consultant and JMO staff to negotiate often leading to frustration and worsened access block.

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“Typically…. I arrange referral to what I think is the most appropriate avenue for my patient’s subacute care only to discover a few days later that that particular service has “declined” the patient and I have to start all over again. This cycle often repeats two or three times. Days turn into weeks…..” - Disgruntled General Medical clinician discussing the RHH referral process for complex patients requiring ongoing care following their acute treatment.

Figure 6: One consultant’s view of discharge planning for complex General Medical patients

Simplification of referral processes to subacute, improvement of the appropriateness of referral and elimination of additional “assessment” steps have been achieved in other health services(40). It is possible to establish a single (or few) point/s of referral to subacute care based on an electronic referral process in which acute staff are “trusted” to place patients on a transparent waiting list according to agreed criteria and documentation (at Alfred Health in Melbourne this is known as the “Caulfield Direct” process). For the vast majority of patients there should be no direct clinical review by the subacute team to delay the process unless the subacute lead in charge of the waiting list identifies reasons to initiate a review or on request from the referring clinician (typically in the case of unusually complex patients). For this process to work a high degree of trust needs to develop between acute and subacute teams that all the available alternatives to non-inpatient avenues to progress the patient’s care have been exhausted or discounted. Hence the importance of daily interdisciplinary acute ward meetings attended by staff with an excellent understanding of not only subacute care but also of non-inpatient, community- based alternatives to inpatient care who can help maintain the integrity of the referral process.

We have already discussed the many alternatives to inpatient care that could be further developed at RHH to ensure that only those patients who really require inpatient subacute care are referred there (see page 28). RHH has much work to do to develop and expand services such as HITH, in-reach to residential aged care, ComRRS, community mental health etc to minimise the presence of “unqualified” patients waiting in medical wards to go to subacute and the occupation of subacute by “unqualified” patients who could be more appropriately cared for in the community. These reviewers believe that this work is of utmost priority in addressing ED access block at RHH as for this patient cohort, access to subacute care is a major bottleneck of the organisation which accounts for days and

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Towards Outstanding Care at RHH – Newnham/Hillis weeks of lost bed days for each “unqualified” patient (as opposed to intensive effort currently expended in the ED to save mere minutes and hours).

“A bed is a bed is a bed….. whether it is in EMU, acute or subacute. All bed days wasted at sites of a bottleneck to flow have a disastrous effect on inpatient access, wherever they are located. Improvement efforts must be focussed on these bottlenecks”. – HN

RECOMMENDATION 3.9

Develop a simple criterion-based process, agreed between acute and subacute staff, that allows acute staff to initiate electronic referral and acceptance of patients to subacute care that also enhances appropriateness of referral.

As part of “Good Ward Governance” for all wards that refer frequently to subacute care, mandate daily interdisciplinary discussions about all patients who potentially require that care. These discussions should include input from staff knowledgeable about subacute care and its non-inpatient alternatives. On every occasion these meetings should be attended by senior acute medical decision makers and preferably also subacute representatives.

Governance and fiduciary responsibility for alternative pathways to inpatient care should reside at least in part together with responsibility for subacute care to encourage optimal use of resources and to foster exploration of alternative models of care.

Intensive Care Unit at RHH (ICU)

RHH ICU has an onerous responsibility. It has 18 funded intensive care beds (23 physical spaces), but is often flexed up to 21 patients in the unit. As the highest acuity ward in RHH and, indeed, in the state it needs to be able to continuously provide timely admission and safe care to extremely unwell patients from a wide variety of sources. In addition, ICU beds are several times as expensive to maintain as ward beds so flexing up capacity when there are “unqualified” patients in the unit is a costly and inefficient practice.

“Two weeks ago a complex emergency patient with an overdose went to ICU. There was no bed in the ward and so the patient was there for days. Mental health refused to have them under the department of psychiatry bed card so they eventually went to the ward under a specialty unit but with no medical issues. The patient was specialled in the ward for fourteen days, then discharged home.” “We often have eight to ten patients “flagged” to go but only get one ward bed” - Frustrated clinicians RHH

Access to ICU contributes directly to ED access block and risk when a patient in a resuscitation cubicle in ED who requires ICU is unable to be moved there because there are no available beds (see above quote).

Unfortunately, patient flow issues frequently impact on RHH ICU. Almost a third (32%) of ICU discharges are delayed by more than 12 hours because of lack of bed availability in the ward. Some patients may stay in ICU for several days without any issues requiring ICU care. ICU staff are often frustrated by calls without notice regarding patients having planned high-risk surgery at RHH or at nearby private hospitals when they could have been involved in more appropriate operative scheduling to plan ICU bed availability.

ICU staff also mentioned that a commonly used emergency treatment of stroke, stroke thrombolysis, at RHH has a mandatory requirement for a 24 h ICU admission. Once the acute episode is over however the patients frequently stay in the ICU bed for many days because of delayed access to acute stroke or rehabilitation beds. One solution for this problem is for the thrombolysis treatment to take place in a dedicated area within the stroke ward by appropriately trained staff, a common practice in other acute

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Towards Outstanding Care at RHH – Newnham/Hillis teaching hospitals with stroke services. Similarly, some other hospitals have expanded the scope of normal ward practice in areas such as non-invasive ventilation (NIV)(41) and high flow oxygen therapy with appropriate supports in place so that these treatments do not necessarily involve admission to the ICU and can be delivered safely and rapidly to patients who need them in the ward.

Managing access to the ICU is often a daunting role. Clinicians and flow managers are faced with the daily task of prioritising who is most deserving of an ICU bed; the sick patient in ED, the sick patient in the ward or the sick patient in theatre recovery, or the patient currently being retrieved from the scene of an accident by ambulance services. They also need to decide who is the least sick patient to move from the ICU to the general ward and who they can keep waiting in the ED so that there is a space in the general ward! This process of governance of ICU access needs to involve trust and timely collaboration between a wide variety of players: ICU leadership, flow managers, inpatient clinicians, theatre managers, clinical stream leads and the surgeons who do high risk operations. We believe there is scope to improve ICU access and safety and quality of care at RHH by developing clearer pathways of communication between ICU and non-ICU clinicians and flow leaders, particularly in advance of complex high risk surgery and during daily flow discussions.

RECOMMENDATION 3.10

Establish clear guidelines and timely communication channels for complex decision making regarding prioritisation of patients for ICU beds. This should include planning of high risk surgery in both public and nearby private facilities and in discussion of requests for inter- hospital transfers. (see earlier discussion regarding IT approaches to communication).

Develop a thrombolytic treatment regimen for acute stroke patients that can be provided in the acute stroke ward and that does not require mandatory ICU admission.

Consider other treatments that may be safely delivered in non-ICU wards with a revised model of care, such as Non-Invasive Ventilation (NIV) and delivery of high flow oxygen therapy.

Prioritise improvement work on reducing the delay for transfer of ICU patients to ward beds.

General Medicine as a case study

We have chosen to consider the General Medicine service as the most important inpatient case study to feature in this review because we believe the General Medicine service at RHH holds an important under-realised key to reducing access block. Excluding EMU admissions, General Medicine sees more than 2.5 fold the number of patients admitted to the next busiest unit at RHH (general surgery which has 1982 admissions or 12% of non-EMU admissions). Not only is General Medicine the largest group of patients admitted to overnight beds at RHH after EMU (General Medicine is responsible for 18% of all admissions or 27% of non-EMU admissions at RHH). But also General Medicine is the service capable of contributing the most to “defragmenting” the care (including inpatient, ambulatory and community care) of the increasingly complex mix of patients attending RHH. The University of Tasmania report from 2014(18) also indicated that “Complex, Chronic, & Community Care patients warrant special attention as they represent 6% of the hospital and 17% of bed-day usage.

A highly responsive and interdisciplinary General Medical service committed to finding the best solution for progressing care of patients with a mix of chronic diseases, social disadvantage often accompanied by mental health, cognitive or addiction issues is essential to a highly functioning health service. This care needs to be provided seamlessly across inpatient and ambulatory care in the community and with broad agreement and effective collaboration with all other RHH services. It also needs to be informed by consumer and carer input from those with lived experience of the service.

Much of the feedback we received from staff suggested that the flow of patients from ED to the General Medical service and on to discharge is a potential major bottleneck in overall patient flow at RHH. In the

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Towards Outstanding Care at RHH – Newnham/Hillis absence of true data measured for improvement we therefore make the assumption (Sutton’s law) that focussing on improving patient flow through General Medicine is of the highest priority for RHH. It is very likely that lessons learnt from thorough improvement work to improve General Medicine patient throughput and quality of care will apply to other units and services at RHH.

Progression of care of General Medical patients is severely impaired from the time of a decision to admit in ED by the workload confronting the two basic physician trainee (BPT) medical registrars in the daily receiving team. These two doctors are responsible for up to 20 admissions per day as well as attendance at all MET calls (average of at least 5 a day, often more). It is generally agreed that a single JMO should be responsible for no more than an average of 5 complex new admissions per shift(42). It is therefore not surprising that agreed timelines for clerking of these patients are rarely met, with patients often waiting many hours in the ED to the frustration of the ED staff. As discussed above “pushback” is an inevitable consequence of having an unmanageable workload.

A shift to a “distributive” admission model in which new patients referred to the unit are allocated evenly across all four General Medical teams on a continuous basis would provide a regular daily workload for JMO staff in General Medicine. This should, if combined with co-location of the AMU patients with the rest of General Medical patients, lead to improved continuity of care, improved patient flow and simpler staff rostering. Instead of a single team receiving 20 patients, each of the four teams would receive 5 patients across 24h, constituting an acceptable, manageable workload that gives time for JMO to provide quality care and to communicate effectively with their interdisciplinary teams and the patient, family and carers.

There is also scope to modify the current JMO staff rostering in General Medicine to improve progression of patient care in and after hours, including across weekends whilst simultaneously addressing overtime issues. There are at least 14 JMO registrars in the General Medical service roster. These doctors work mostly in a business hours roster with stretched after hours cover. The reviewers are not privy to the current extent of rostered or un-rostered overtime although anecdotal information suggested that the latter was highly significant and typically under-reported, contributing to staff distress. It would be appropriate to model the impact of switching to a week-on and week-off roster that in other organisations has been associated with a high degree of staff satisfaction and improved after hours and weekend progression of care with minimal unrostered overtime. This system substantially increases staff availability between 5 and 9pm, a traditionally busy time for clerking registrars and can ensure that each patient is rounded-on each day of the weekend by a registrar who knows them well and can accordingly progress and discuss their care. It should also reduce handoffs of un-clerked patients to overnight staff by the afternoon/evening staff, improving flow of patients in the evening and overnight and hence reducing access block and pressures on overnight staff. From the registrar perspective it ensures highly protected time off to pursue recreational, social and other interests or further their studies during the week off. This arrangement at the Alfred Hospital general medical service is well accepted and popular with JMO staff and has led to only a single significant BPT registrar complaint in the last 6 years.

Many General Medical services in Australian hospitals now include a daily consultant ward round. RHH General Medicine has a “tailing approach” where the consultant sees the entire unit’s new patients on the post receiving day and the next day and retains care of these patients even although visiting only intermittently on subsequent days. We believe a daily discussion on site, reviewing any barriers to progression of care, should occur between each of the four team’s consultants and registrars. This could be combined with reviewing the regular flow of new patients arising from the distributive admission model discussed above but may require consultants to reorganise their daily commitments.

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RECOMMENDATION 3.11

Improving progression of care in General Medicine:

Shift to a distributive admission model for General Medicine in which new patients referred to the unit are distributed evenly across all four teams on a continuous basis to provide a regular predictable and manageable workload for JMOs and consultants.

Develop a model for daily morning consultant review of inpatients by each team’s consultant.

Separate MET call registrar responsibility from that of the acute medical receiving call role as much as possible.

Match JMO staff rosters with predictable time of high workload to improve safety and ensure care progresses 24/7

Institute week-on/week-off longer shift rosters to reduce handovers and improve accessibility of JMO staff to patients and families and ensure staff have meaningful rostered time off with minimal unrostered overtime.

Develop an agreed expectation regarding consistency, timing and frequency of consultant ward rounding for all services, monitored by each interdisciplinary leadership group

Review the role of the APU to evaluate whether the same goals could not be met by a simpler, single General Medical service model situated away from the ED, with strict co- location of patients with their managing team (few or no outliers) and effective referral paths to appropriately experienced allied health staff.

Report weekly performance data designed to ensure investigative and other specialty units provide timely responses to referrals from inpatients after they have left the ED and arrived in the ward.

Simplify the referral process for subacute care, rehabilitation and home-based services, HITH, Geriatric support at home, etc down to a single number for all referrals with transparent real-time waiting list management.

Develop a hospital-at-night program to improve the capability of wards to safely receive patients overnight, and reduce staff stress. This program should facilitate a team approach to shared task management overnight amongst all rostered staff, including some floating nursing staff credentialed for minor procedures (IVC, IDC). Time to task completion, particularly to review of deteriorating patients should be a key KPI.

Surgical and Perioperative Services at Royal Hobart Hospital

There are 12 surgical specialties within this service, including the state-wide services of vascular surgery, trauma and neurosurgery. General Surgery and Orthopaedics have a strong relationship with the ED department being in the top 6 specialties by ED admissions. General Surgery operates within an Acute Surgical model with a responsive approach to ED presentations. They highlighted the inadequacy of undertaking surgical consultations and assessments within ED corridors or in ambulance bays. Bed pressures commonly result in patients becoming “outliers” away from their home unit’s ward, reducing the efficiency of surgical care, prolonging length of stay and exposing patients to the risk of care from staff less experienced with their condition.

Despite increased use of the surgical Short Stay Unit and the Same Day Surgery ward, Surgical Services access block means that they may only be able to admit to 60% of their allocated beds on any one day. They have a high expectation that allocation of more beds within the new K block development will resolve this. There have been initiatives to address the waiting lists by utilising beds in the Hobart Private Hospital annex and arrangements for lists to be undertaken in other private hospitals.

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Unfortunately, changes at the Hobart Private Hospital have seen the number of beds available substantially decreased. The viability of other hospitals undertaking the surgical work was removed when the funds available to outsource the work was reduced to only 75% of the Activity Based Funding level.

The service is now reliant on ‘elective surgery surges’ being funded as an ‘extra event’ to manage the waiting lists in a reactive manner. This is not a long term strategy nor a coherent management approach. Often the political imperative driving these surges does not align with the most appropriate clinical priorities in dealing with the waiting lists. The service anticipates achieving only Category 1 Waiting List requirements but expresses grave concerns about meeting KPIs for the other waiting list categories. Access to overnight beds is uncertain on any day of the week. Although the first operating theatre case will commence even as bed access is being confirmed, all other cases may be cancelled when access to beds is denied.

As for the medical services, the surgical teams also have ongoing challenges in accessing rehabilitation or sub-acute beds. Treatment of acquired brain injury patients was particularly highlighted as an area requiring additional bed based resources but also more community-based support. The Neurosurgery service could have 50% of their patients awaiting rehabilitation assessment and treatment at any one time. The discharge of patients needing ongoing care, but not further surgical intervention, is difficult when the patient needs to return to the hospital who has referred the patient to the state wide service

There has been an active program to try and address issues of engagement and empowerment of the Surgical and Perioperative Services. A number of the part time (VMO) positions have been converted into Full time positions on staff. This has been in the Orthopaedic and Neurosurgery specialties. As with other services we noted that there was not a uniform allocation of protected non-clinical time for administrative purposes for Heads of Unit (see page 12).

The sense of being accountable, data driven and responsible in this service was particularly strong, which speaks to the effectiveness of the Clinical Leadership model. However, there were concerns about how to engage effectively with clinical service planning, meaningful allocation of budgets and the ability to have services such as Hospital in the Home recognised, prioritised and funded.

The surgical leadership were highly suspicious of the accuracy of local data being reported to the Health Round Table for benchmarking of performance, quality and safety, including data on length of procedure time within the operating theatre, use of blood products and rates of day surgery separations. An audit of the clarity of the data and the definitions utilised is required to restore confidence.

At RHH as in other hospitals it is common for inpatients awaiting a procedure to be cancelled or “bumped” from their intended theatre list at the last minute, usually in favour of more acute patients. This process if often repeated on subsequent days and contributes to patient deterioration and deconditioning whilst they wait and is often complicated by long periods of fasting. It also contributes to patient frustration, prolonged length of stay, hospital acquired complications and poor flow, access block and increased costs. RHH should develop an effective system that alerts those responsible for theatre/laboratory lists when a patient has been cancelled and ensures that they receive a timely, guaranteed substitute time and are not risk dropping to the bottom of the list on a subsequent day. An accurate “fasting clock” system should also be developed so that prolonged periods of fasting are tracked and minimised.

These reviewers did not evaluate the systems and processes nor efficiency of the utilisation of RHH operating theatres other than some discussion above regarding the day case and short stay approaches.

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RECOMMENDATION 3.12

Develop a system with appropriate capacity to protect elective surgical stream/beds to improve elective surgical performance. In the short term this may require greater engagement with private hospitals.

Undertake regular reviews of same day surgery approach to ensure international ‘better’ practice.

Develop effective monitoring and escalation processes and a “fasting clock” to ensure that inpatients awaiting theatre/laboratory procedures are not subject to sequential cancellations or prolonged fasting

Mental Health

The reviewers had only a single meeting with mental health leadership to inform this review. We were however shocked to see from data the extent to which ED access block at RHH impacts on mental health patients. These patients are overrepresented in the large numbers of patients who spend more than twenty-four hours in the ED. Indeed, in March 2019, the average length of stay in the ED was 21.3 hours for mental health patients and the average wait for an Acute Inpatient Mental Health Bed was more than 2 days (53 hours) although anecdotal evidence suggested that a stay of up to seven days was not uncommon. These mental health patients are spending up to several days in the inappropriate underground environment of the ED that is ill equipped to deliver the quality of care they deserve. It is possible that, for many patients, this environment actually exacerbates their illness and extends their length of stay.

Despite these substantial ED access pressures for mental health patients, the mental health leadership are strongly of the view that the solution lies in greater capability and capacity for ongoing support in the community rather than an increase in acute inpatient mental health beds at RHH. The Trieste model(43) is held up as a strong community-based model of care that has proven highly successful in a jurisdiction not too dissimilar to that of Hobart’s in Tasmania. The mental health leadership have submitted a paper to the THS to outline what is required to achieve this locally. An ability to provide high levels of consultant-led diagnosis, treatment and management of acute exacerbations of psychiatric illness outside of the ED and to provide ongoing support to these patients as they recover in a safe and familiar environment that includes availability of supportive accommodation is surely an appropriate goal. As is the primary prevention of psychiatric deterioration by lowering of barriers to access to care in the community.

The mental health leadership are of the view that the costs of comprehensive care based in the community will be less than the costs of the current approach of predominantly hospital based care, accepting that there will need to be a period of overlap of both approaches during development of the community approach. On the basis of the information in front of us, including plans already in place to provide some additional acute assessment beds for mental health patients at RHH, these reviewers would support the proposed community-based model of care for mental health patients, which is in agreement with the broader approach of enhancing community-based care for all of Hobart that flows throughout this review.

RECOMMENDATION 3.13

RHH and THS work to progress plans to rapidly improve community-based mental health care as proposed in the modified Trieste model under development as a primary action to relieve acute access block for mental health patients.

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Glossary of terms

ACU: Accountable Care Unit – ward model in which nurse manager and physician manager partner to manage all aspects of ward governance.

APU: Admission and Planning Unit, RHH

Better@Home: A geriatrician, nursing and allied health service delivering rehabilitation in the home for elderly patients, Alfred Health, Melbourne.

DOS: Daily Operating System. A term used in many hospitals (including in Victoria) to describe the daily networking of key leadership, informed by real time data and close connection with front line teams, who together provide timely responses to issues arising that affect patient access and throughput in the organisation.

EMU: Emergency Medical Unit, RHH

HITH: Hospital-in-the-Home

IOC: Integrated Operational Centres that manage beds and flow for the organisation

MATS: Mobile Assessment and Treatment Service, a geriatrician and nurse led outreach service to patients in residential aged care facilities, Alfred Health, Melbourne

MCAPS: Making Care Appropriate for Patients – a software tool from Oak Group International

Qualified: The patient is at the correct level of care to meet his/her medical needs. The intensity of clinical services required to treat the patient as delineated by the physician’s plan of care cannot be provided at a lower level of care.

Non-Qualified: The patient could be treated at a different, usually lower level of care to meet medical needs. Includes existing and potential levels of care. Social or environmental issues preventing transfers to lower levels of care are blockages or impediments to appropriate placement.

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References

(1) Holmes A. Health union claims man died in Royal Hobart Hospital emergency department after waiting for seven hours. The Examiner. 2019 APRIL 13 2019 - 1:15PM. (2) COUNCIL A. Background Paper - Access Block. ACEM; 2014. Contract No.: S127. (3) Mitra B, Cameron PA, Archer P, Bailey M, Pielage P, Mele G, et al. The association between time to disposition plan in the emergency department and in-hospital mortality of general medical patients. Internal medicine journal. 2012;42(4):444-50. (4) Lowthian J, Curtis A, Straney L, McKimm A, Keogh M, Stripp A. Redesigning emergency patient flow with timely quality care at the Alfred. Emerg Med Australas. 215;27(1):35-41. (5) Duckett S, Cuddihy M, Newnham H. Targeting zero. Supporting the Victorian hospital system to eliminate avoidable harm and strengthen quality of care. Report of the Review of Hospital Safety and Quality Assurance in Victoria. Melbourne; 2016 October 2016. Report No.: ISBN 978-0-7311-6966-5 (pdf/online). (6) Travis DG. Travis Review. Increasing the capacity of the Victorian public hospital system for better patient outcomes. Final report June 2015. Victoria, Australia; 2015 June 2015. (7) Jones P, Wells S, Ameratunga S. Towards a best measure of emergency department crowding: Lessons from current Australasian practice. Emerg Med Australas. 2018;30(2):214-21. (8) NHS DoH. The NHS plan. A plan for investment. A plan for reform. London: Comptroller and Auditor General; 2000 July 2000. Contract No.: Department of Health. (9) Richardson DB, Mountain D. Myths versus facts in emergency department overcrowding and hospital access block. Med J Aust. 2009;190(7):369-74. (10) Duckett S, Nijssen-Jordan C. Using quality improvement methods at the system level to improve hospital emergency department treatment times. Quality Management in Health Care.21(1):29-33. (11) Staib A, Sullivan C, Griffin B, Bell A, Scott I. Report on the 4-h rule and National Emergency Access Target (NEAT) in Australia: time to review. Aust Health Rev. 2016;40(3):319-23. (12) Morley C, Unwin M, Peterson GM, Stankovich J, Kinsman L. Emergency department crowding: A systematic review of causes, consequences and solutions. PLoS One. 2018;13(8):e0203316. (13) Kreindler SA. Six ways not to improve patient flow: a qualitative study. BMJ Qual Saf. 2017;26(5):388-94. (14) DHHS_Tasmania. One State, One Health System, Better Outcomes. Rebuilding Tasmania’s Health System ISSUES PAPER. 2014. (15) Auditor-General T. Performance of Tasmania’s four major hospitals in the delivery of Emergency Department services. Report of the Auditor General. 2019 May 2019. Report No.: No. 11 of 2018-19. (16) Minister. Ministerial Charter, Tasmanian Health Service Act 2018: Department of Health; 2018 [cited 2019 14 July 2019]. Available from:

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https://www.dhhs.tas.gov.au/__data/assets/pdf_file/0010/344737/Ministerial_Charter_T HS_July18.pdf. (17) DHHS_Tasmania. DELIVERING SAFE AND SUSTAINABLE CLINICAL SERVICES WHITE PAPER One State, One Health System, Better Outcomes. 2015. (18) UTAS_Health_Reform_Consulting. Final Report for Health Services Innovation. Hobart, Tasmania: University of Tasmania; 2014. (19) Castle BW, Shapiro SE. Accountable Care Units: A Disruptive Innovation in Acute Care Delivery. Nursing Administration Quarterly. 2016;40(1):14-23. (20) Atkinson S, Spurgeon P, Clark J, Armit K. Engaging Doctors: What can we learn from trusts with high levels of medical engagement? Coventry 2011. (21) Spurgeon P, Mazelan PM, Barwell F. Medical engagement: a crucial underpinning to organizational performance. Health Serv Manage Res. 2011;24(3):114-20. (22) AMA_Victoria_and_DHHS. AMA Victoria - Victorian Public Health Sector - Medical Specialists Enterprise Agreement 2018-2021. 2018. (23) Braithwaite J, Clay-Williams R, Vecellio E, Marks D, Hooper T, Westbrook M, et al. The basis of clinical tribalism, hierarchy and stereotyping: a laboratory-controlled teamwork experiment. BMJ Open. 2016;6(7):e012467. (24) Newnham HH, Villiers Smit D, Keogh MJ, Stripp AM, Cameron PA. Emergency and acute medical admissions: insights from US and UK visits by a Melbourne tertiary health service. Med J Aust. 2012;196(2):101-3. (25) Mosadeghrad A, Ansarian M. Why do organisational change programmes fail? International Journal of Strategic Change Management. 2014;5:189. (26) Kotter JP. Accelerate! Harv Bus Rev. 2012;90(11):44-52, 4-8, 149. (27) Kotter JP, Rathgeber H. Our Iceberg is Melting: Changing and Succeeding Under Any Conditions. MA: St Martin's Press; 2006. (28) Ocloo J, Matthews R. From tokenism to empowerment: progressing patient and public involvement in healthcare improvement. BMJ Quality & Safety. 2016;25(8):626-32. (29) Physicians RCo. Delivering the future hospital November 2017 Full report. London; 2017. Report No.: eISBN 978-1-86016-699-0. (30) RCP. Future hospital: Caring for medical patients. A report from the Future Hospital Commission. London: Royal College of Physicians; 2013. (31) Hall RW. Patient Flow, Reducing Delay in Healthcare Delivery (Springer, 2006). 2006. (32) Kreindler SA. Six ways not to improve patient flow: a qualitative study. BMJ Quality & Safety. 2017;26(5):388-94. (33) Goldratt EM CJ, . The goal: a theory of constraints.1984. (34) Newnham AH. Clinicians trade in risk, a conversation. 2019. (35) Brockman K. Submission to Legislateive Council Sessional Committee Government Administration: Sub-Committee on Acute Health Services in Tasmania 2017 [cited 2019 14th July 2019]. Available from: http://www.parliament.tas.gov.au/ctee/Council/Submissions/HST/35%20Kate%20Brock man%20(2).pdf.

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(36) Nandram S, Koster N. Organizational innovation and integrated care: lessons from Buurtzorg. Journal of Integrated Cae. 2014;22(4):172-84. (37) Tong EY, Roman C, Mitra B, Yip G, Gibbs H, Newnham H, et al. Partnered pharmacist charting on admission in the General Medical and Emergency Short-stay Unit - a cluster-randomised controlled trial in patients with complex medication regimens. J Clin Pharm Ther. 2016;41(4):414-8. (38) Frank C, Weir E. Deprescribing for older patients. CMAJ. 2014;186(18):1369-76. (39) Hale G, McNab D. Developing a ward round checklist to improve patient safety. BMJ Qual Improv Rep. 2015;4(1):u204775.w2440. (40) McAlister FA, Bakal JA, Majumdar SR, Dean S, Padwal RS, Kassam N, et al. Safely and effectively reducing inpatient length of stay: a controlled study of the General Internal Medicine Care Transformation Initiative. BMJ Qual Saf. 2014;23(6):446-56. (41) Scala R, Pisani L. Noninvasive ventilation in acute respiratory failure: which recipe for success? Eur Respir Rev. 2018;27(149). (42) Scott I, and Statewide General Medicine Clinical Network. Position Statement. Staffing and Activity Levels for General Medicine Units in Queensland. Queensland: Queensland Health; 2019. (43) Mezzina R. Community mental health care in Trieste and beyond: an "open door-no restraint" system of care for recovery and citizenship. J Nerv Ment Dis. 2014;202(6):440-5.

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Appendix 1. Excerpts from MCAPS 2017

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55 Towards Outstanding Care at RHH - Newnham/Hillis Appendix 2. Recommendations of previous reviews Part A: Ordered by review / Part B: Ordered by classification

PART A

REVIEW RECOMMENDATIONS BY REVIEW Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility Commission 2014. 1 Data. A lack of reliable and comparable data, particularly Data / Information High 3 Within 12 2 6 relating to hospital costs, has restricted our ability to draw / IT months definitive conclusions in some areas and is a significant impediment to effective management of the system. Commission 2014. 2 Service configuration. Tasmania’s hospitals provide a range of Governance / org Moderate 2 Within 3 1 2 services in relatively low volumes that is typically not structure years matched in hospitals of similar size, function, and location in other parts of Australia. As a consequence, Tasmanians have local access to a broader range of public hospital services than residents of comparable regions. There is a lack of a coherent statewide framework for service provision, with inappropriate duplication of services across multiple organisations. Commission 2014. 3 System performance. Alarmingly high numbers of overdue Surgical wards / High 3 Immediate 3 9 patients on elective surgery waiting lists and high rates of units access block and GP‐type presentations in emergency departments require urgent attention. Commission 2014. 4 Funding. The Commonwealth is undertaking considerable Governance / org Low 1 Within 3 1 1 additional investment in the Tasmanian health system under structure years the Tasmanian Health Assistance Package. Governments should take stock of whether all initiatives are well‐targeted to improve the sustainability of the Tasmanian health system.

Commission 2014. 5 The new governance arrangements in Tasmania are not Governance / org High 3 Immediate 3 9 functioning in a manner conducive to achieving a sustainable structure health system. There is confusion about roles and responsibilities and a lack of accountability for performance.

Commission 2014. 6 Considerable efficiencies, not yet realised in the move Governance / org Moderate 2 Within 12 2 4 towards the devolved DHHS/THO structure, can be gained structure months from improvements in operational management of the Tasmanian health system. Commission 2014. 7 Clinical redesign. Clinical redesign is needed to address Change High 3 Within 12 2 6 serious problems with patient access to care and the management months efficiency of clinical and administrative practices. The success of the redesign program will be highly dependent on leadership and buy‐in at all levels—from the Minister, THO Governing Councils and executives, and clinicians—and a commitment to a consistent and rigorous approach to identifying priorities. Commission 2014. 8 Management of elective surgery. Tasmania is not prioritising Surgical wards / Moderate 2 Within 12 2 4 elective surgery patients sensibly or transparently and many units months patients are waiting far too long for surgery. There needs to be a systematic approach to elective surgery categorisation and management; efficiency in theatre utilisation; utilisation of private sector capacity; and appropriate role delineation for where surgery is performed.

Commission 2014. 9 Clinical engagement. Clinician engagement is pivotal to Engagement and High 3 Immediate 3 9 successful redesign and operation of the Tasmanian health empowerment system. Urgent attention is required to determine the most suitable and sustainable approaches for clinician engagement in the planning and management of the system.

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PART A

REVIEW RECOMMENDATIONS BY REVIEW Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility Commission 2014. 10 Like clinical engagement, the engagement of consumers is Consumer / patient Moderate 2 Within 3 1 2 vital to the effective management of the health system. The involvement years benefits of community understanding of, and input into, health system decision‐making have not yet been realised in Tasmania. Commission 2014. 11 Changing culture. Poor leadership and bad behaviour is at the Culture High 3 Immediate 3 9 core of Tasmania’s inability to achieve both effective governance and sustainable change. No move to improve the health system will succeed without cultural change. Commission 2014. 12 Infrastructure. Major infrastructure investment, particularly Number of beds Moderate 2 Within 12 2 4 the Royal Hobart Hospital redevelopment, has not been months sufficiently informed by whole‐of‐system planning and system sustainability. Commission 2014. 13 Improving efficiency. Further work is required to improve Data / Information High 3 Within 12 2 6 data quality, but Tasmania appears to have higher hospital / IT months costs, particularly for services with low volumes. Commission 2014. 14 Service planning and reconfiguration. Further consideration Governance / org Moderate 2 Within 3 1 2 of the perceived benefits of regional self‐sufficiency must be structure years balanced with the benefits that can be achieved through increased collaboration across the Tasmanian health system. Commission 2014. 15 That the roles, responsibilities, authorities and lines of Governance / org High 3 Immediate 3 9 accountability across the Tasmanian health system be clearly structure identified, formalised and embedded in a range of available tools, including Ministerial Policy, Ministerial Charters, Service Agreements and performance requirements. Commission 2014. 16 That the THO Governing Councils be reconfigured to oversee Governance / org ## ## 0 the performance of the THO functions consistent with the structure THO Act, Commission 2014. 17 That the existing Performance Framework be accepted and Governance / org Moderate 2 Within 12 2 4 embedded across the system, including through Ministerial structure months Charters and Service Agreements. Commission 2014. 18 That DHHS review the existing Ministerial Charters to assess Governance / org Low 1 Within 12 2 2 the extent to which they have been complied with and what structure months sanctions are applied for non‐compliance. Commission 2014. 19 That the Minister issue the endorsed Clinical Governance Governance / org Moderate 2 Within 12 2 4 Framework as a Ministerial Policy to prioritise its structure months operationalisation across the system, supported by both the State and THO clinical governance committees. Commission 2014. 20 That the Minister endorse DHHS’s establishment of an Governance / org Moderate 2 Within 12 2 4 overarching system‐wide Clinical Governance Committee, as structure months the peak body for the implementation of the clinical governance framework, including representation from each of the Governing Councils and the TML. Commission 2014. 21 That THOs establish clinical governance committees at the Governance / org High 3 Immediate 3 9 local level to lead and monitor clinical performance, reporting structure to their respective Governing Councils and the overarching system‐wide Clinical Governance Committee. Commission 2014. 22 That the statewide and THO clinical governance committees Governance / org High 3 Immediate 3 9 jointly establish procedures for implementation of system‐ structure wide safety and quality policy, consistent with the national framework promulgated by the Australian Commission 2014. on Safety and Quality in Health Care. Commission 2014. 23 That planning and delivery of both clinical services and Governance / org Moderate 2 Within 12 2 4 support services occur within a statewide policy framework, structure months through a collaborative process led by DHHS.

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PART A

REVIEW RECOMMENDATIONS BY REVIEW Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility Commission 2014. 24 That the Minister issue policy directions outlining: a system‐ Governance / org Moderate 2 Within 12 2 4 wide vision, strategic direction, and requirements for structure months planning and collaboration within the Tasmanian health system; and a statewide Service Capability and Purchasing Policy to guide statewide service planning and delivery. Commission 2014. 25 That the Ministerial Charters be expanded to require each Governance / org ## ## 0 THO Governing Council to submit to DHHS its strategic structure directions on an annual basis, including detail on how the THO will meet its purpose and strategic objectives consistent with Part 2 of the current Ministerial Charters. Commission 2014. 26 That a business case be developed for a shared service entity Governance / org Moderate 2 Within 3 1 2 to provide functions (including but not limited to supplies, structure years equipment, payroll, finance operations, business systems, procurement services, asset management services and a shared information technology system) to DHHS and the THOs, in a cost‐effective, efficient and integrated fashion. This may involve entering into partnership arrangements with other jurisdictions. Commission 2014. 27 That a Health Advisory Council, chaired by the Secretary of Governance / org Moderate 2 Within 12 2 4 DHHS and comprising the THO Governing Council Chair(s), the structure months TML CEO, clinicians and healthcare providers, be established to provide advice to the Minister on statewide service planning and integration. Commission 2014. 28 That the Minister revisit the implementation of new Governance / org Low 1 Within 3 1 1 governance arrangements under the THO Act within the next structure years two years to assess the impact of any corrective action taken and to consider whether legislative change is necessary to achieve the policy intent of the Act. Commission 2014. 29 That DHHS and the THOs ensure that operational Governance / org High 3 Immediate 3 9 management roles, responsibilities and delegations are structure clarified and communicated effectively as a matter of highest priority. Commission 2014. 30 That DHHS and the THOs take responsibility for embedding Governance / org Moderate 2 Within 12 2 4 effective performance management processes within the structure months system. Commission 2014. 31 That managers be supported and provided with the Engagement and Moderate 2 Within 12 2 4 appropriate tools to undertake regular and effective empowerment months performance review of all staff, and that this support is also provided to Governing Councils in order that they fulfil their role in relation to CEO and system performance. Commission 2014. 32 That DHHS take immediate steps to centralise and reform Governance / org Moderate 2 Within 12 2 4 administrative functions, starting with Payroll and HR structure months services, across DHHS and the THOs. Commission 2014. 33 That the Minister direct the DHHS to immediately lead a Governance / org Moderate 2 Within 3 1 2 systematic review of all the administrative functions of the structure years health system, modelled on HR and Payroll process reviews recently undertaken, to identify and remediate inefficient and out‐of‐date practices. Commission 2014. 34 That the conduct of the review and the implementation of its Governance / org Moderate 2 Within 12 2 4 recommendations be overseen by appropriate governance structure months arrangements, including the involvement of the Tasmanian Department of Treasury and Finance. Implementation will be guided by an agreed plan of action including milestones and key performance indicators.

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PART A

REVIEW RECOMMENDATIONS BY REVIEW Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility Commission 2014. 35 That a small external panel of population health experts Governance / org Low 1 Within 12 2 2 undertake a review of Population Health Services division of structure months DHHS, with a view to recommending significant reforms involving integration with other services. These reforms should include a process of prioritising key functions and decentralising where possible. Commission 2014. 36 That senior management be given an efficiency dividend to be Governance / org Low 1 Within 12 2 2 achieved through the reform and restructuring arising from structure months the Commission 2014. ’s recommendations on operational efficiency. Commission 2014. 37 That DHHS progress its activities to improve statewide ICT Governance / org High 3 Within 12 2 6 systems as a matter of priority, ensuring that any work structure months undertaken is effective and builds on investments already made in ICT system and network upgrade projects. Commission 2014. 38 That THO Governing Councils and CEOs take responsibility for Change High 3 Within 12 2 6 driving a culture for clinical redesign that is systematic, uses a management months consistent and rigorous methodology, and focuses on statewide priorities. Commission 2014. 39 That the University of Tasmania engage external expertise to Change ## ## 0 mentor and support managers and clinicians in building management clinical redesign capacity and to assist it in the development of its clinical redesign training program. Commission 2014. 40 That priority be given in the establishment phase of the Change High 3 Immediate 3 9 clinical redesign program to the following areas: developing management robust governance arrangements; establishing program leadership; undertaking comprehensive stakeholder engagement and building an understanding of clinical redesign throughout the system; establishing Clinical Lead positions in THOs and connecting with the TML Health Pathways positions; providing additional support and mentoring in redesign methodology; determining priority areas for redesign focus and investment through a rigorous statewide diagnostic process; developing a Strategic Plan for work over the longer term; and building strategic alliances with clinical redesign experts. Commission 2014. 41 That, as a matter of urgency, THOs introduce a more Surgical wards / Moderate 2 Within 12 2 4 systematic approach to elective surgery categorisation and units months management. This should include mechanisms to prioritise the provision of surgery to overdue patients, such as adopting a ‘treat in turn’ policy for scheduling surgery other than for reasons of clear clinical need. Commission 2014. 42 That DHHS and the THOs monitor and report on the Surgical wards / Moderate 2 Within 12 2 4 proportion of ‘treat in turn’ surgery in a consistent and units months transparent way. Commission 2014. 43 That commitment be made to a longer‐term Elective Surgery Surgical wards / Moderate 2 Within 12 2 4 Plan for Tasmania that goes beyond annual budget cycles and units months is cost‐effective and sustainable. Commission 2014. 44 That Tasmania, through the University of Tasmania’s Clinical Surgical wards / ## ## 0 Redesign Program, commit to a diagnostic analysis across the units continuum of surgery management to identify where improvements and efficiencies can be made within the system, including: developing models to separate elective and emergency surgery, initially through a demand/capacity matching analysis for each stream; and analysing theatre management to identify impediments to efficiency and patient flow.

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PART A

REVIEW RECOMMENDATIONS BY REVIEW Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility Commission 2014. 45 That funding be made available under Element D of the Surgical wards / ## ## 0 Tasmanian Health Assistance Package (THAP) for a specific units focus on elective surgery redesign. Commission 2014. 46 That DHHS, as the purchaser of hospital services, develop a Partnerships across High 3 Within 12 2 6 broader range of purchasing options that includes the private the entire health months and non‐government sectors, and that THOs actively engage sector with private hospitals to explore and develop service delivery partnerships. Commission 2014. 47 That the THO Governing Councils set goals to substantially Surgical wards / Moderate 2 Within 12 2 4 improve elective surgery waiting list management and reduce units months the rate of elective surgery postponements. Commission 2014. 48 That the process for managing patients on the elective Surgical wards / Moderate 2 Within 12 2 4 surgery waiting list be refined to ensure that practices are units months equitable, transparent and consistent across the state Commission 2014. 49 That DHHS ensure a standard approach to elective surgery Surgical wards / Moderate 2 Immediate 3 6 categorisation as an immediate priority, based on the advice units of the Tasmanian Statewide Surgical Services Committee Commission 2014. 50 That DHHS lead a collaborative process to develop a surgical Surgical wards / Moderate 2 Within 12 2 4 pathway for patients that maps demand and identifies units months alternative models of patient care. Commission 2014. 51 That a diagnostic analysis be undertaken to review the high Surgical wards / Moderate 2 Within 12 2 4 level of hospital‐initiated postponements, and that service units months redesign requirements be identified and implemented. Commission 2014. 52 That DHHS develop a safe, efficient and viable framework for Surgical wards / Moderate 2 Within 12 2 4 the delivery of surgical services at both statewide and local units months service levels. Commission 2014. 53 That DHHS consider undertaking an external, independent Surgical wards / Moderate 2 Within 12 2 4 review of Tasmanian surgical mortality data, including audit units months data collected through the Tasmanian Audit of Surgical Mortality. Commission 2014. 54 That the THO Governing Councils increase clinician Engagement and High 3 Immediate 3 9 involvement in Governing Council meetings to receive empowerment information and advice on health system issues, and to provide their input on clinical governance. Commission 2014. 55 That the development and implementation of a clear process Change Moderate 2 Within 12 2 4 for clinical handover for Tasmania be undertaken. This should management months involve working closely with clinicians, the TML, THOs and other key stakeholders in the health system. Commission 2014. 56 That Clinical Advisory Groups be formed as a priority, with Engagement and High 3 Immediate 3 9 clear and agreed terms of reference; and be utilised empowerment effectively as a conduit between clinicians and administrators.

Commission 2014. 57 That THOs consider implementing the use of clinician Engagement and Moderate 2 Within 3 1 2 compacts as an opportunity to improve engagement between empowerment years a health service and Visiting Medical Officers (VMOs). Commission 2014. 58 That consideration be given to appointing ‘clinical champions’ Engagement and High 3 Within 12 2 6 to: enable the promulgation of best practice and innovation empowerment months (including clinical redesign); and lead the development of collaborative clinical partnerships within and across specialties and sectors. Commission 2014. 59 That a comprehensive statewide community engagement and Consumer / patient Moderate 2 Within 3 1 2 capacity building strategy be developed and implemented as involvement years a matter of priority. This strategy should seek to increase health literacy, health system awareness and advocacy skills. We recommend that funding to support this initiative be sourced from Element D of the Tasmanian Health Assistance Package.

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PART A

REVIEW RECOMMENDATIONS BY REVIEW Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility Commission 2014. 60 That the Tasmanian Minister for Health, in his agreements Culture High 3 Immediate 3 9 with the Governing Councils, emphasise his expectation of positive leadership of, and collaboration between, THOs and all clinical stakeholders, including the TML, to drive cultural change. Commission 2014. 61 That senior officials and clinical leaders in the healthcare Culture High 3 Immediate 3 9 system, in fulfilling their roles, be required to conform to the highest degrees of professionalism, honesty and integrity, and act in a manner consistent with the Code of Conduct under section 9 of the State Service Act 2000. Commission 2014. 62 That the Governing Councils make cultural change and Culture High 3 Immediate 3 9 leadership one of their main priorities. Commission 2014. 63 That an approach to whole‐of‐system leadership training is Engagement and High 3 Within 12 2 6 provided for all managers (clinical and administrative) of the empowerment months health system. This could be delivered through the University of Tasmania, in conjunction with other relevant institutions. Commission 2014. 64 That clinical and administrative leaders of the three THOs and Change High 3 Within 12 2 6 DHHS strengthen their strategic capability in change management months management by participating in appropriate performance development. Commission 2014. 65 That the three THOs and DHHS implement a well‐planned Change High 3 Within 12 2 6 change management process, including actively seeking staff management months engagement at all levels through a program of regular staff consultation. Commission 2014. 66 That the Royal Hobart Hospital redevelopment be placed on Number of beds ## ## 0 hold, to ensure that a full and comprehensive service plan is developed in the context of the resources available to build and operate the service as part of a statewide health system.

Commission 2014. 67 That DHHS, as a matter of urgency, undertake a review to Data / Information High 3 Immediate 3 9 identify and remedy the causes of significant costing data / IT variations. Commission 2014. 68 That DHHS, supported by the Commission 2014. , undertake Data / Information ## ## 0 an audit of data management practices across DHHS and the / IT THOs, funded from Element D of the THAP. Commission 2014. 69 That DHHS, consistent with its role of system oversight, be Data / Information High 3 Within 12 2 6 the steward of a statewide approach to data management. / IT months Commission 2014. 70 That there be recognition that pursuing a high level of Governance / org Moderate 2 Within 12 2 4 regional self‐sufficiency across a range of acute care services structure months is a potential risk to the safety and quality of patient care and impacts upon operational efficiency and system sustainability. Current levels of local acute care provision need to be assessed on this basis. Commission 2014. 71 That DHHS, as system manager, promote whole‐of‐system Partnerships across High 3 Immediate 3 9 collaboration to expand on, and maximise the benefits of the entire health primary care initiatives, such as Health Pathways, Care sector Coordination, and Streamlined Care Pathways programs, with the aim of adopting a more patient‐centred approach to health care across the system. Staib 2016. 1 Define “timely” and have this definition agreed for each Data / Information High 3 Immediate 3 9 phase of care (ED, inpatient, discharge) / IT Staib 2016. 2 Performance is benchmarked and communicated and data is Data / Information High 3 Within 12 2 6 available to staff to monitor and guide clinical redesign / IT months Staib 2016. 3 Patients first initiative is prioritised and progress against Governance / org High 3 Within 12 2 6 previous Monaghan report is measured structure months

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PART A

REVIEW RECOMMENDATIONS BY REVIEW Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility Staib 2016. 4 The case for a short stay unit (SSU) at LGH be considered in RHH leadership Moderate 2 Within 12 2 4 the light of accurate data including the potential impact on about priorities months inpatient admissions and NEAT performance, but most /policies importantly, the current numbers of patients who would benefit from SSU care Staib 2016. 5 Excellent clinical redesign already underway is encouraged Change Moderate 2 Within 12 2 4 management months Staib 2016. 6 Contemporaneous organisational charts for both sites are Governance / org Moderate 2 Immediate 3 6 released structure Staib 2016. 7 A structure be considered for inpatient services, particularly Medical wards / ## ## 0 Medicine and Surgery, that facilitates streamlining and units consistency of the ED‐inpatient interface Staib 2016. 8 Accountability for metrics and the authority to undertake Governance / org High 3 Immediate 3 9 process and policy change are aligned. structure Staib 2016. 9 Effective clinical leadership is prioritised at both sites Engagement and High 3 Immediate 3 9 empowerment Staib 2016. 10 Staff culture survey is released and an operational plan is Culture Moderate 2 Within 12 2 4 completed to address findings months Staib 2016. 11 Staff updated on evidence that improved flow improves Goal / vision High 3 Immediate 3 9 outcomes. Such shared understanding that the ED‐inpatient interface affects patient outcomes should enhance ED and inpatient team collaboration to focus on improved flow Staib 2016. 12 A focus on data sharing and patient outcomes rather than just Data / Information High 3 Within 12 2 6 process measures such as time in order to accelerate clinical / IT months engagement Staib 2016. 13 Patient outcomes must remain at the centre of all care Goal / vision High 3 Immediate 3 9 delivered Staib 2016. 14 ED staff have admitting rights against bilaterally agreed Engagement and High 3 Immediate 3 9 (between inpatient and ED staff) admission guidelines empowerment Staib 2016. 15 Escalation procedures are implemented in a timely manner in RHH leadership High 3 Immediate 3 9 order to pre‐empt access block about priorities /policies Monaghan 2012. 1 Addressing the misguided belief that ED is the driver and sole Goal / vision High 3 Immediate 3 9 beneficiary of process reform. Monaghan 2012. 2 Implementation of Clinical Pathways. As a matter of urgency, Engagement and High 3 Immediate 3 9 pathways for #NOF, code STEMI, Haematemesis & Melaena, empowerment and Paediatric/Adult Asthma pathways should be implemented Monaghan 2012. 3 Reviewing the clinical justification of the GOC and ADDS ED department Moderate 2 Within 12 2 4 Forms’ application to every adult patient, which anecdotally months delays some transfers from ED to the ward. Monaghan 2012. 4 Requests for increasing FTE without associated redesign of ED department Moderate 2 Within 12 2 4 processes are unlikely to provide significant benefit from a months productivity perspective. Monaghan 2012. 5 As there will be an activity shift to the inpatient areas RHH leadership Moderate 2 Within 12 2 4 especially in after hours and acute units investing in staffing about priorities months for these areas will be necessary. /policies Monaghan 2012. 6 The order of priority of bed allocation for different areas such Improving patient High 3 Immediate 3 9 as APU, ED and elective surgery needs review. flow / bed management Monaghan 2012. 7 Review of the current practice whereby APU patients Medical wards / High 3 Immediate 3 9 admitted in ED overnight can’t go to APU after 0800hrs and units instead wait in ED for a ward bed. Monaghan 2012. 8 The development of a mechanism to alert the hospital to ED RHH leadership High 3 Within 12 2 6 overcrowding and a Ramping response, and a practical about priorities months hospital escalation policy /policies

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REVIEW RECOMMENDATIONS BY REVIEW Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility Monaghan 2012. 9 The benefits of a well utilized Transit Lounge for enhancing Improving patient High 3 Immediate 3 9 discharge practice are well documented. It will be important flow / bed to think about improving access to this area in expectation of management completion of the capital works. Monaghan 2012. 10 Suggest that the ED CNS or NUM could attend Patient Flow Improving patient High 3 Immediate 3 9 meetings in order to create rapport between ED and the flow / bed wards especially given the ward NUMs attendance. management Monaghan 2012. 11 The role of the after‐hours Patient Flow Manager and role Improving patient High 3 Immediate 3 9 consistency need to be addressed because it impacts on flow / bed timely patient access to beds from ED. management Monaghan 2012. 12 Improved communication between ED and bed management, Improving patient ## ## 0 including review of the process of notifying ED of bed flow / bed allocations. management Monaghan 2012. 13 There would be value in analysing the most recent bed Data / Information High 3 Within 12 2 6 capacity audit, or repeating an audit to determine what other / IT months initiatives may enhance hospital capacity. Monaghan 2012. 14 Implement and enforce a safe, consistent admissions policy Improving patient High 3 Immediate 3 9 that allows patients to move safely from ED to the wards, flow / bed without unnecessary delay including always needing to have management inpatient review in ED. Monaghan 2012. 15 Review of the current practice of holding short stay paediatric Improving patient Moderate 2 Immediate 3 6 admissions in ED rather than sending them to the children’s flow / bed ward. management Monaghan 2012. 16 The current common practice of waiting on the full workup of Improving patient High 3 Immediate 3 9 the patient and the admission team’s review prior to flow / bed requesting a bed needs to cease. management Monaghan 2012. 17 We would also suggest that the department consider a 2,1,1 ED department High 3 Immediate 3 9 time guide rather than 1,2,1. Two hours for ED review, stabilization, referral and bed booking, one hour for inpatient review, and one hour for movement to the ward. Monaghan 2012. 18 Addressing the structure and policy around bed booking slips Improving patient Moderate 2 Within 12 2 4 and redesigning the current form to include more relevant flow / bed months patient history and current clinical requirements. management Monaghan 2012. 19 The transfer policy, which relates to whether patients require ED department High 3 Immediate 3 9 a nurse escort, has been in place since October 2010 but not adhered to. Monaghan 2012. 20 The ED SSU is currently inadequate, and needs to be larger, ED department Moderate 2 Within 12 2 4 with dedicated medical staffing, and appropriate level nursing months staffing to safely accommodate monitored patients when required. Monaghan 2012. 21 We would recommend a change to the nursing patient flow Improving patient High 3 Immediate 3 9 position that is currently in place. To counter the problems of flow / bed inconsistency and potentially junior staff within the role, we management would suggest that this role be changed to a substantive position, Monaghan 2012. 22 The issues around identifying nursing or medical staff ED department Moderate 2 Immediate 3 6 responsible for a particular patient in ED could be quickly sorted by a mandatory, brief “huddle” of nursing and medical staff in their respective areas at the start of each shift.

Monaghan 2012. 23 The observation that there were FACEMs within the ED department Moderate 2 Immediate 3 6 department who did not participate actively in enhancing patient flow raises the question of whether there is still significant work to be done to engage this group.

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PART A

REVIEW RECOMMENDATIONS BY REVIEW Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility Monaghan 2012. 24 The current situation of lack of KPIs around ED processes ED department High 3 Within 12 2 6 needs to be corrected, and these then need to be used to months identify process inefficiencies within the ED. We suspect there are areas of inefficiency in the ED that are not currently recognizable without mapping and data. Monaghan 2012. 25 The availability of protocols for medical and nursing staff in Engagement and High 3 Immediate 3 9 areas such as streaming to admission or discharge streams empowerment and admission pathways needs to be addressed. Monaghan 2012. 26 Review the current ED nursing/medical reviews, which ED department High 3 Within 12 2 6 presently result in repetition of pt. assessments. months Monaghan 2012. 27 The current EDIS program available to the department does Data / Information Moderate 2 Within 12 2 4 not demonstrate increasing LOS in a form that would prompt / IT months activity on patients that were having extended stays within the department. Monaghan 2012. 28 The Hospital Intranet needs to be updated to enable access to Data / Information High 3 Immediate 3 9 relevant, up to date policies and guidelines as currently many / IT policies are outdated and not utilised. Monaghan 2012. 29 Review the effectiveness of the current Escalation Tool RHH leadership High 3 Immediate 3 9 relating to ED overcrowding. about priorities /policies Monaghan 2012. 30 The flow of subspecialty patients through the APU during Medical wards / High 3 Within 12 2 6 standard working hours be reconsidered, as this seems to units months offer very little additional value to patient care. Monaghan 2012. 31 The APU in our opinion needs 24 hour registrar cover, with a Medical wards / High 3 Immediate 3 9 second registrar available to cover the wards after hours. units Monaghan 2012. 32 APU access to radiology is problematic; a possible solution Medical wards / Moderate 2 Immediate 3 6 would be to allow APU to use ED orderlies and the ED units radiology department given their close proximity rather than needing to use the upstairs radiology department. Monaghan 2012. 33 It is clear that for all staff involved, the conflict within the Medical wards / High 3 Immediate 3 9 medical division in terms of the direction the APU model will units take needs to be resolved as early as possible. Monaghan 2012. 34 That a proforma admission sheet, or an electronic medical Data / Information High 3 Within 12 2 6 record model be considered for improving efficiencies in the / IT months medical clerking process. Monaghan 2012. 35 The current situation of bed availability occurring after 1300‐ Improving patient High 3 Immediate 3 9 1400hrs each day is unacceptable. The solution to this comes flow / bed from many of the initiatives already mentioned in the management recommendations above. Monaghan 2012. 36 A 24‐ hour radiographer service be created for ED as a matter ED department High 3 Within 12 2 6 of urgency. months Monaghan 2012. 37 The current process of obtaining a plain film in the ED be ED department Moderate 2 Within 12 2 4 reviewed and leaned down. months Monaghan 2012. 38 The installation of a PACS screen in ED was highlighted as a ED department Moderate 2 Within 12 2 4 possibility to improve access to imaging results. months Monaghan 2012. 39 Data to be collected to inform a case for ultrasound and ED department High 3 Within 12 2 6 possibly CT regular slots to be made available for the ED. months Monaghan 2012. 40 A tiered approach be considered for prioritizing radiology RHH leadership Moderate 2 Within 12 2 4 access throughout the hospital, with an emphasis on about priorities months availability for acute and critical care areas. /policies Monaghan 2012. 41 A simple solution to be implemented in ED, such as laminated ED department Low 1 Immediate 3 3 signs to identify patients who are booked for ultrasound, to minimize inadequate preparation resulting in cancelled procedures. Monaghan 2012. 42 Have a pre‐ramping policy and ramping policy, at the very RHH leadership High 3 Within 12 2 6 least to create a consistent response to the situation. about priorities months /policies

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REVIEW RECOMMENDATIONS BY REVIEW Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility Monaghan 2012. 43 There should continue to be regular meetings with Partnerships across Moderate 2 Immediate 3 6 Ambulance Tasmania, and concerted efforts by the ED staff, the entire health especially the coordinators and triage nurses, to keep the sector ambulance crews informed of progress and attempts to create capacity. Monaghan 2012. 44 The option of “removing ramping”, by letting the patients be ED department High 3 Immediate 3 9 dropped off by an ambulance crew into an overcrowded department, is in our opinion never an option. Monaghan 2012. 45 The solution to ramping is to enhance movement of patients Goal / vision High 3 Immediate 3 9 through the ED and the greater hospital Monaghan 2012. 46 While out of scope for this review, we would like to raise the Partnerships across Low 1 Within 3 1 1 question of whether there is wisdom in a free ambulance the entire health years service with 50% of the cases being referred to the waiting sector room. UTAS 1 Implement (modify if required) a hospital admissions policy. RHH leadership High 3 Immediate 3 9 Review the current admission decision process in ED. about priorities /policies UTAS 2 Redesign patient flow processes and systems. Change High 3 Within 12 2 6 management months UTAS 3 Redesign ward length of stay management and discharge Change High 3 Immediate 3 9 planning practices. management UTAS 4 Discuss and collaborate with Ambulance Tasmania service. Partnerships across Moderate 2 Within 12 2 4 the entire health months sector UTAS 5 Review the current state of ‘voice of the patient’ Consumer / patient Moderate 2 Within 3 1 2 involvement years UTAS 6 Review the current state of ‘voice of the staff’ Culture High 3 Within 12 2 6 months UTAS 7 Ensure a robust change management strategy appends the Change High 3 Immediate 3 9 broader redesign programs. This should be inclusive of a management definitive communications strategy across the organisation, stakeholder engagement plan and hospital wide change plan.

UTAS 8 Undertake site visits to high performing organisations across Improving patient High 3 Within 12 2 6 Australia of similar size and complexity. flow / bed months management UTAS 9 Review and implement ward leadership and flow Improving patient High 3 Immediate 3 9 management training. flow / bed management UTAS 10 Review ED staffing profiles. ED department Moderate 2 Within 12 2 4 months UTAS 11 Review imaging services. RHH leadership Moderate 2 Within 12 2 4 about priorities months /policies UTAS 12 Review hospital operations escalations (predictive and RHH leadership High 3 Immediate 3 9 reactive). about priorities /policies UTAS 13 Review and implement ED team‐based care and patient ED department High 3 Immediate 3 9 streaming. UTAS 14 Review and implement the ED Navigator role. ED department Moderate 2 Immediate 3 6 UTAS 15 Review bed flexing practices (ICU/HDU). RHH leadership High 3 Within 12 2 6 about priorities months /policies UTAS 16 Review the current nurse escort and transfer policy. ED department Moderate 2 Immediate 3 6 UTAS 17 Review APU. Medical wards / High 3 Immediate 3 9 units

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REVIEW RECOMMENDATIONS BY REVIEW Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility UTAS 18 Review EMU. ED department High 3 Immediate 3 9 UTAS 19 Review the medical patient journey from admission decision, Improving patient High 3 Immediate 3 9 bed request and bed ready. flow / bed management UTAS 20 There was notable variation in the performance across wards Improving patient High 3 Immediate 3 9 in terms of discharge requirements, planning, and flow / bed destination. management UTAS 21 Key qualitative conclusions in this section are: Improving patient High 3 Immediate 3 9 1. There was strong evidence of empty beds across the flow / bed hospital which ward staff were unsure of who the next management patient allocated to those beds. 2. There was a cohort of patients who were occupying beds whilst waiting for non‐clinical steps which was indicative of a lack of patient journey planning. 3. There was a large cohort of patients who were occupying beds for non‐acute clinical reasons therefore contributing to latent capacity in the hospital (i.e. discharge requirements, discharge destination, discharge planning, and transfer of care). UTAS 22 It was noted that there was a high patient outlier rate across Improving patient High 3 Immediate 3 9 the hospital with an inconsistent management approach. flow / bed management UTAS 23 The bed meeting appeared to lack a focus on resolving ED Improving patient High 3 Immediate 3 9 over‐crowding. flow / bed management UTAS 24 There is variability in management practices and priority with Improving patient High 3 Immediate 3 9 respect to patient flow and length of stay management at a flow / bed ward level covering nursing and medical staff. management UTAS 25 Ward staff did not appear to be aware of ED workload levels Sharing of risk High 3 Immediate 3 9 and therefore respond accordingly (e.g. ED overcrowding, ambulance ramping) in a manner that alleviated ED patient loads. UTAS 26 There appeared to be a significant disconnect between the RHH leadership High 3 Immediate 3 9 published hospital escalation policy and the hospital wide and about priorities executive response to ED over‐crowding, ward LOS /policies management and overall bed management. UTAS 27 Accountability and responsibility for patient flow through the Improving patient High 3 Immediate 3 9 wards was unclear in terms of “who is running the hospital” flow / bed on a minute by minute, hour by hour and day by day management operational basis. Pt First. 1 A list of unacceptable ‘red flag’ events in Tasmanian Health ED department High 3 Immediate 3 9 Service (THS) Emergency Departments (EDs) Pt First. 2 Evidence based escalation policies RHH leadership High 3 Immediate 3 9 about priorities /policies

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REVIEW RECOMMENDATIONS BY REVIEW Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility Pt First. 3 Transparent, published principles for ED Care: On arrival to Change High 3 Immediate 3 9 ED, all patients will be seen within 30 minutes by a member management of a consultant‐led, interdisciplinary team who will initiate assessment, investigations and treatment; Patients will be discharged from the ED or admitted to the hospital as decided by the ED consultant staff; Patients will be reviewed by an inpatient team within two hours of arrival on a ward; Patients will be admitted to a bed in the most appropriate clinical place, first time; Patients will have investigations, consultations and interventions completed as soon as possible, in order of request or clinical priority and where practical within 24/24; Patients will be reviewed daily by a decision‐making clinician in collaboration with the patient/carer; Hospital resources, including human resources, will be allocated according to system priorities based upon accurate data; Working hours and rosters for front line clinicians will be managed to ensure staff are available when required to ensure safe patient care; Patients will be cared for in the facility most appropriate to their current clinical need ensuring they are only in hospital for as long as clinically necessary. Pt First. 4 Clinical Initiative Emergency Nurses ED department Moderate 2 Within 12 2 4 months Pt First. 5 Psychiatric Emergency Nurses Mental health / Moderate 2 Immediate 3 6 services Pt First. 6 More efficient discharge Improving patient High 3 Immediate 3 9 flow / bed management Pt First. 7 Better Discharge Planning Improving patient High 3 Immediate 3 9 flow / bed management Pt First. 8 Winter Illness Strategies RHH leadership High 3 Immediate 3 9 about priorities /policies Pt First. 9 Working Better with Private and Not‐For‐Profit Hospitals Partnerships across High 3 Within 12 2 6 the entire health months sector Pt First. 10 Timely Discharge Summaries RHH leadership Moderate 2 Immediate 3 6 about priorities /policies Pt First. 11 Better Utilisation of Rural Hospital Beds Partnerships across High 3 Immediate 3 9 the entire health sector Pt First. 12 Connecting patients to bulk billing GPs Partnerships across Moderate 2 Within 12 2 4 the entire health months sector Pt First. 13 Enhanced role for paramedics Partnerships across Moderate 2 Within 12 2 4 the entire health months sector Pt First. 14 Support for very long stay patients Improving patient High 3 Immediate 3 9 flow / bed management Pt First. 16 Recognising the role of clinical leadership Engagement and High 3 Immediate 3 9 empowerment Pt First. 17 Statewide consistent Admissions Policies Governance / org High 3 Within 12 2 6 structure months

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REVIEW RECOMMENDATIONS BY REVIEW Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility Pt First. 18 Statewide Clinical Handover Framework Governance / org High 3 Immediate 3 9 structure Pt First. 19 Any other measures to improve patient flow Improving patient Moderate 2 Within 12 2 4 flow / bed months management TAS AG. 1 THS and DoH take urgent action to strengthen whole‐of‐ Governance / org High 3 Immediate 3 9 health system leadership and coordination of initiatives structure designed to improve patient flow by, at a minimum: (a) clarifying the roles and responsibilities of all hospital Executive Directors of Operations, mental health services and primary and community care leadership teams, inpatient wards, department heads, clinicians, nurses and related administrative and support staff in prioritising and contributing to hospital and system‐wide initiatives to improve patient flow TAS AG. 1B (b) ensuring all hospital, mental health and community care Engagement and High 3 Within 12 2 6 leadership teams, department heads and their staff are fully empowerment months empowered, sufficiently resourced and accountable for achieving sustained improvements in hospital and system‐ wide collaboration and performance on patient flow TAS AG. 1C (c) taking immediate steps to review and, where relevant, Improving patient High 3 Immediate 3 9 strengthen the effectiveness of coordination mechanisms flow / bed between all departments and staff within hospitals and with management mental health, primary and community care services for optimising patient flow. TAS AG. 2 THS and DoH urgently review the root causes of the growth in Sharing of risk High 3 Immediate 3 9 ED adverse events and implement targeted initiatives to mitigate the impacts and reduce future incidences. TAS AG. 3 THS and DoH urgently implement a culture improvement Culture High 3 Immediate 3 9 program and initiatives with clearly defined goals, accountabilities and timeframes to: (a) eliminate the longstanding dysfunctional silos, attitudes and behaviours within the health system preventing sustained improvements to hospital admission, bed management and discharge practices (b) ensure that all THS departments and staff work collaboratively to prioritise the interests of patients by diligently supporting initiatives that seek to optimise patient flow. TAS AG. 4 THS and DoH develop an effective sector‐wide consultation Engagement and High 3 Immediate 3 9 and engagement strategy to support sustained improvements empowerment in patient flow that, at a minimum, provides: (a)education to staff on the need for, and merits of, whole‐of‐hospital action to reduce access block through more effective and efficient admission, bed management and discharge practices and the benefits to patient care and safety that come from improved patient flow (b) genuine opportunities for THS staff to contribute to and influence the design, development and implementation of hospital and sector‐wide patient flow reform initiatives. TAS AG. 5 THS and DoH expedite the development and implementation Improving patient High 3 Within 12 2 6 of proactive strategies that effectively leverage the insights of flow / bed months the 2017 Clinical Utilisation Study to both reduce and management minimise the incidence of avoidable admissions and non‐ qualified continuing days of stay for admitted patients.

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PART A

REVIEW RECOMMENDATIONS BY REVIEW Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility TAS AG. 6 THS strengthen support to, and the accountability of, health RHH leadership High 3 Immediate 3 9 system leadership teams for improving their performance in about priorities sustainably reducing the rate of avoidable admissions and /policies non‐qualified continuing days of stay for admitted patients. TAS AG. 7 THS and DoH review and strengthen the: (a)change Change High 3 Within 12 2 6 management capability and skills of THS and hospitals to management months ensure future reform initiatives are adequately supported and deliver sustained behaviour change and impact (b) project management capability of THS and hospitals to ensure future reform initiatives are underpinned by effective implementation and delivery planning processes that are regularly monitored. TAS AG. 8 THS and DoH review and, where relevant, action outstanding Governance / org High 3 Immediate 3 9 recommendations from the Patients First, Staib Sullivan and structure Monaghan reviews. TAS AG. 9 DoH, in consultation with THS, expedite development of the Governance / org Moderate 2 Within 12 2 4 revised THS Performance Framework. structure months TAS AG. 10 DoH, in consultation with THS, strengthen performance Improving patient Moderate 2 Within 12 2 4 monitoring and reporting processes to ensure they: flow / bed months (a)provide actionable insights into the root causes of management performance issues affecting ED access and care (b) ensure related improvement actions address the root causes of performance issues and are likely to succeed (c) rigorously assess the merits of alternative escalation/improvement actions in circumstances of consistent underperformance. EDAP 1.1.1 The Secretary of the Department of Health and senior clinical Goal / vision High 3 Immediate 3 9 leaders commit to a vision of a highly integrated health service from the acute through sub‐acute and mental health sectors to the community EDAP 1.1.2 Establish a committee charged with implementation of the Governance / org High 3 Immediate 3 9 recommendations of this review together with the structure outstanding high priority, still relevant recommendations of previous reviews (see appendix) within 2 years. This committee should be chaired by the Secretary and include senior hospital administrative and clinical leadership (including Mental health) and community representation. EDAP 1.2.1 Recruitment processes be revised to ensure a nationally Governance / org High 3 Within 12 2 6 competitive, timely and responsive appointment cycle structure months EDAP 1.2.2 Review and minimise the current practice of making short Governance / org High 3 Within 12 2 6 term appointments for clinical staff operational roles. structure months EDAP 1.3.1 Identify where the former board roles to support and appoint Governance / org High 3 Within 12 2 6 the Executive Director of Operations (or equivalent manager), structure months and provide oversight of quality and safety, risk management, strategy, audit, organisational culture, consumer advice and financial responsibility reside in the current THS/DoH structures. Regularly monitor and transparently report on them. EDAP 1.3.2 Adjust the governance of the THS and Northern / Southern Governance / org High 3 Immediate 3 9 hubs by having the senior manager of both the ‘Southern structure Hub’ and the ‘Northern Hub’ on the THS Executive, thus reporting directly to the Secretary. EDAP 1.3.3 Clarify the role of the Senior Executive at the Southern Hub / Governance / org High 3 Immediate 3 9 RHH to ensure that all clinical services including Mental structure Health, ambulatory care and community services are appropriately integrated into the clinical executive structure.

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PART A

REVIEW RECOMMENDATIONS BY REVIEW Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility EDAP 1.3.4 Hold the senior clinical leadership accountable for operational Engagement and High 3 Within 12 2 6 efficiency, budgetary, safety and quality portfolios and empowerment months activities that contribute to patient flow within their streams by developing relevant KPIs that are reflected in detailed annual performance reviews. EDAP 1.3.5 Introduce a “Good Ward Governance” program in which Governance / org High 3 Immediate 3 9 unit/ward interdisciplinary leadership teams (medical, structure nursing, allied health, pharmacy) meet monthly with a standardised agenda and quality reports, and are responsible at local ward/unit level for reviewing performance, improving patient flow and implementing other improvements as agreed by the hospital clinical leadership executive.

EDAP 1.4.1 RHH should insist that those in leadership positions provide Engagement and High 3 Within 12 2 6 evidence of ongoing professional development in leadership empowerment months and improvement science skills. This should be reflected in position descriptions, job advertisements, job interviews and during annual performance appraisals EDAP 1.4.2 Senior leaders should be given the opportunity of mentored Engagement and High 3 Within 12 2 6 leadership training with appropriate local or national empowerment months agencies. EDAP 1.5.1 Clinical leaders including unit heads and substantial FTE Engagement and High 3 Within 12 2 6 clinical appointees should have non‐clinical support time that empowerment months reflects their responsibilities for portfolios including staff management, safety, quality, improvement/development, education and research duties – up to 0.5 EFT for heads of very large and complex units and 0.2 EFT for other full time appointments. The expectations of these non‐clinical roles should be clearly defined and these staff should be held accountable for their achievements in these portfolios during annual performance reviews.

EDAP 1.5.2 Hold second‐monthly “Executive Road Shows” open to all Culture High 3 Within 12 2 6 staff in which senior administrative and clinical leaders, and months occasionally system leaders, outline current organisational priorities, performance initiatives and directions for the future. These should be held in a theatre style session with substantial opportunities for ad lib questions from the staff, using an anonymous digital format. EDAP 1.6.1 The Department Secretary commits to, and resources, an Culture High 3 Immediate 3 9 ongoing cultural change program fostering both a “can‐do” culture of continuous improvement in patient outcomes as well as RHH becoming a truly “great place to work”. EDAP 1.6.2 Strengthen and resource the governance, leadership and Governance / org High 3 Immediate 3 9 capability of health service delivery improvement at RHH, structure with initial focus on improving hospital flow and access. EDAP 1.6.3 Encourage reciprocal staff visits to, and communication with, Engagement and Moderate 2 Within 12 2 4 exemplar hospitals empowerment months EDAP 1.6.4 Barriers to improvement based on arguments of “clinician RHH leadership High 3 Immediate 3 9 autonomy” need to be immediately called out for what they about priorities are so that better patient outcomes become the first priority. /policies EDAP 1.7.1 Acknowledge that, despite pockets of excellence, change Change High 3 Immediate 3 9 management across the system has a very poor recent record management and requires serious and systematic attention.

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PART A

REVIEW RECOMMENDATIONS BY REVIEW Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility EDAP 1.7.2 The THS/DoH enlist the help of a capable external agency (eg Change High 3 Within 12 2 6 IHI) to support RHH for the next 2‐3 years to both implement management months a change management program focussed on improving patient flow and also to develop local skills and capability for future change. Opportunities for collaboration with interstate agencies should be explored. EDAP 1.7.3 That change management to improve patient flow should Change High 3 Within 12 2 6 extend outside the hospital to the development of responsive management months community‐based healthcare services with funding models that incentivise these changes. EDAP 1.8.1 Each major clinical service at RHH should host a biennial Consumer / patient Moderate 2 Within 12 2 4 consumer forum chaired by trained facilitators, (ideally involvement months consumer leads), and attended by unit medical and nursing heads aimed at adapting care processes to meet consumer concerns. EDAP 1.8.2 Consider including consumer representatives in Root Cause Consumer / patient Moderate 2 Within 12 2 4 Analyses and formulation of recommendations regarding involvement months major clinical events and resourcing the required consumer training. EDAP 1.8.3 Consider including appropriately skilled consumers on Consumer / patient Moderate 2 Within 12 2 4 interview panels for medical and substantial non‐medical involvement months leadership positions at RHH. EDAP 1.8.4 Include consumers wherever possible in organisational Consumer / patient Moderate 2 Within 12 2 4 improvement design initiatives and resource the required involvement months consumer training. EDAP 1.8.5 Empower patients to call out unexpected delays. Establish the Consumer / patient Moderate 2 Within 12 2 4 practice of informing patients of what will happen next before involvement months leaving the bedside; what they are waiting for, and how long the wait is expected to be so that if it doesn’t happen they can call it out. Ensure each patient knows the name of the clinician in charge of their care EDAP 1.9.1 Develop capability to measure data for improvement that Data / Information High 3 Immediate 3 9 monitors for “bottlenecks” to patient flow and that has the / IT capability to identify “qualified” and “non‐qualified” patients (as per MCAPS). EDAP 1.9.2 Further develop and audit the accuracy of integrated Data / Information High 3 Immediate 3 9 reporting systems for safety, performance improvement, / IT quality assurance and risk. EDAP 1.9.3 Develop a process for action on Health Round Table data Data / Information High 3 Within 12 2 6 where there are persistent ‘red flags’: currently areas of / IT months pressure care, length of procedures, use of blood, complications and day surgery activities. EDAP 1.10.1 Develop a digital strategy that includes implementation of a Data / Information High 3 Within 12 2 6 fit for purpose electronic medical record (strategy 12 months, / IT months implementation 4 years). EDAP 1.10.2 Approval of new data systems should in the interim be limited Data / Information Moderate 2 Immediate 3 6 to those that can be effectively integrated with the chosen / IT service. EDAP 1.10.3 Evaluate electronic ordering systems for key diagnostic and Data / Information High 3 Within 12 2 6 service areas keeping in mind eventual requirements for / IT months integration with the EMR. EDAP 1.10.4 Improve communications between clinical staff both in and Data / Information Moderate 2 Within 12 2 4 outside the hospital using safe technology that fosters better, / IT months safe decision making (instant messaging and videoconferencing apps)

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PART A

REVIEW RECOMMENDATIONS BY REVIEW Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility EDAP 2.1.1 Undertake an educational project for staff designed to Culture Moderate 2 Within 12 2 4 increase understanding of the importance of sharing of risk months across the system. EDAP 3.1.1 The DoH should work with nearby primary care and locum Partnerships across Moderate 2 Immediate 3 6 organisations to enhance, publicise and refer patients to the entire health them as an alternative to ED attendance 24/7. sector EDAP 3.1.2 Strengthen leadership, capability and governance of health Culture High 3 Within 12 2 6 service delivery improvement science work, aimed at months developing a “can‐do” culture of effective change, with initial focus on improving hospital flow and access.. EDAP 3.1.3 Improve access to outreach/care coordination and other Subacute / geriatric High 3 Within 12 2 6 community‐based services especially for patients in months residential care and patients in their own private residences with frailty or multiple complex chronic disease. EDAP 3.1.4 Develop a single coordinated unit working between the Change High 3 Within 12 2 6 hospital and community to progress programs that reduce management months patient presentations and can deliver specialised nursing services and hospital specialty opinions in the community EDAP 3.1.5 Develop funding models to incentivise hospitals to use them. Change High 3 Within 12 2 6 management months EDAP 3.1.6 Implement suitable models of care to facilitate provision of Alternatives to ED Moderate 2 Within 12 2 4 hospital‐based advice and specialty opinions to support presentation months nursing or medical staff visiting patients outside the hospital (including user friendly videoconferencing). EDAP 3.1.7 Foster discussions with residential aged care services Subacute / geriatric Moderate 2 Immediate 3 6 regarding advanced care plan completion and adherence so there is clear understanding whether or not patients desire transfer to hospital in the event of acute deterioration. EDAP 3.1.8 For Mental Health patients, resource CAT and other Mental health / High 3 Immediate 3 9 community‐based MH teams to provide timely and ongoing services care in the community supported by MH consultant opinion (e.g. videoconference) to minimise transfers to the ED for patients at risk of a crisis. EDAP 3.2.1 Reduce ambulance arrivals: Continue work on primary and Alternatives to ED Moderate 2 Within 12 2 4 secondary triage to deliver care at appropriate community presentation months resources rather than in the ED EDAP 3.2.2 Understand the processes that link patient transport to Alternatives to ED Moderate 2 Within 12 2 4 ambulance attendance to ensure that transport to the ED is presentation months only required when clinically indicated and only after other appropriate options for client management are found to be unavailable EDAP 3.2.3 Work to change community perceptions regarding ambulance Alternatives to ED Moderate 2 Within 12 2 4 utilisation. presentation months EDAP 3.2.4 Review the overcapacity protocol to consider patients whose Alternatives to ED Moderate 2 Within 12 2 4 arrival has been notified by ambulance services to the ED to presentation months be the responsibility of the hospital. EDAP 3.3.1 Inter‐hospital patient transfers: Develop an agreed inter‐ RHH leadership Moderate 2 Within 12 2 4 hospital transfer policy that clearly identifies responsibilities about priorities months of the receiving and transferring units/hospitals regarding /policies acceptance and timely return of patients. EDAP 3.3.2 Private hospitals: The DoH/THS should use their role in Partnerships across High 3 Immediate 3 9 system oversight and management to work with private the entire health services to come to an agreed city‐wide approach to periods sector of access stress and to expand negotiated public use of private inpatient capacity as much as possible until RHH access block persistently resolves

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PART A

REVIEW RECOMMENDATIONS BY REVIEW Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility EDAP 3.4.1 Ensure Ambulatory care services receive appropriate RHH leadership Moderate 2 Within 12 2 4 representation and improvement focus at hospital executive about priorities months level meetings so that clinics provide timely access for /policies referrals from the community and help relieve hospital access block. EDAP 3.5.1 Increase available spaces in the ED and model of care to ED department High 3 Immediate 3 9 support reduction of the transit time for non‐admitted patients and create a high performance 4h KPI for this non‐ admitted patient group. EDAP 3.5.2 Minimise triage time and detail to facilitate rapid streaming ED department Moderate 2 Immediate 3 6 to a senior clinical decision maker who will commence their care in the most appropriate space. EDAP 3.5.3 Collect only a minimum data set at initial patient registration ED department High 3 Immediate 3 9 in ED, completing the collection once a patient’s care has been initiated

EDAP 3.5.4 Implement and monitor performance of the previously RHH leadership High 3 Within 12 2 6 agreed “Timely Quality Care” principles including ED about priorities months consultant authority to admit the patient on interim orders /policies without prior unit review. EDAP 3.5.5 Establish an agreed escalation protocol for unacceptable RHH leadership Moderate 2 Within 12 2 4 delays by inpatient staff responding to requests for opinion about priorities months or notification of admissions by the ED staff. Measure these /policies delays in order to identify the most important opportunities for improvement. EDAP 3.5.6 Implement systems where JMO availability to respond when RHH leadership Moderate 2 Immediate 3 6 referred patients by the ED is maintained even in the setting about priorities of clinic, theatre and ward rounding responsibilities. /policies EDAP 3.5.7 Schedule daily consultant geriatrician rounds through ED and Subacute / geriatric High 3 Immediate 3 9 EMU to facilitate admission diversion plans for complex elderly patients and upskill ED staff on alternative pathways of care. EDAP 3.6.1 RHH and ED management should review annually: RHH leadership Moderate 2 Within 12 2 4 Allied health resourcing and level of experience to ensure about priorities months best possible, timely decision making for the ED and the EMU. /policies Modelling of EMU bed numbers and usage to ensure they are optimally improving overall organisational flow. Staff orientation/education to ensure all staff have a working knowledge of available admission diversion models and referral pathways. EDAP 3.7.1 Review and redesign consultant and JMO staffing and rosters RHH leadership High 3 Immediate 3 9 to facilitate progression of patient care in and out of hours about priorities and across weekends and ensure a realistic workload with /policies minimum overtime. EDAP 3.7.2 Establish agreed protocols (minimum order sets) for the most RHH leadership High 3 Immediate 3 9 common clinical reasons for admission between the ED and about priorities inpatient teams so that all have confidence all necessary tests /policies will be initiated in the ED and completed in a timely manner regardless of when the patient is transferred to the ward. EDAP 3.7.3 For patients in the ward, set tight, transparent KPIs to RHH leadership High 3 Immediate 3 9 minimise delays between ordering and completion of about priorities investigations and referrals found to be most important to /policies the progression of care so that staff are confident they will occur in a timely manner even after the patient has left the ED.

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PART A

REVIEW RECOMMENDATIONS BY REVIEW Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility EDAP 3.8.1 Ensure the IOC acts to connect relevant staff and oversee Improving patient High 3 Immediate 3 9 effective patient flow across the system. flow / bed management EDAP 3.8.2 Monitor and routinely report on “right patient, right bed”; the Improving patient High 3 Immediate 3 9 percentage of patients in each team’s correct geography to flow / bed encourage colocation of patients in the correct beds, management minimise outliers, and foster interdisciplinary teamwork. EDAP 3.8.3 Develop a process to achieve tight KPIs for bed “turnaround” RHH leadership High 3 Immediate 3 9 times, especially isolation cleans. about priorities /policies EDAP 3.8.4 When there is capacity, the IOC should further develop an RHH leadership Moderate 2 Within 12 2 4 admission flex bed model in which beds staffed for a single about priorities months nursing shift are opened at predicted times of peak demand /policies for egress from the ED. These beds should be available in the most likely destination ward to improve correct geography. EDAP 3.8.5 Ensure consistent use of the utilisation of the ‘Paris’ patient RHH leadership Moderate 2 Within 12 2 4 risk screening tool or similar at RHH. about priorities months /policies EDAP 3.8.6 Increase the integration of pharmacists with interdisciplinary Culture Moderate 2 Within 12 2 4 team care at RHH to improve reporting, and reduce months occurrence of, medication errors and foster effective de‐ prescribing practices EDAP 3.8.7 Improve the timely provision of discharge summaries to GPs RHH leadership Moderate 2 Immediate 3 6 and other specialists to improve quality of discharge planning about priorities and minimise the risk of readmission. /policies EDAP 3.8.8 Develop ward rounding checklists that include safety and Improving patient Moderate 2 Immediate 3 6 quality items (status of intravenous lines, urinary catheters, flow / bed goals of care and estimated date of discharge) for use in daily management morning ward rounds. EDAP 3.8.9 Institute ward‐based afternoon board rounds (eg 4 pm) with Improving patient Moderate 2 Immediate 3 6 medical and nursing decision makers to plan all aspects of flow / bed early discharges the following morning. management EDAP 3.9.1 Develop a simple criterion‐based process, agreed between RHH leadership High 3 Immediate 3 9 acute and subacute staff, that allows acute staff to initiate about priorities electronic referral and acceptance of patients to subacute /policies care that also enhances appropriateness of referral. EDAP 3.9.2 As part of “Good Ward Governance” for all wards that refer Improving patient Moderate 2 Immediate 3 6 frequently to subacute care, mandate daily interdisciplinary flow / bed discussions about all patients who potentially require that management care. These discussions should include input from staff knowledgeable about subacute care and its non‐inpatient alternatives. On every occasion these meetings should be attended by senior acute medical decision makers and preferably also subacute representatives. EDAP 3.9.3 Governance and fiduciary responsibility for alternative Governance / org Moderate 2 Immediate 3 6 pathways to inpatient care should reside at least in part structure together with responsibility for subacute care to encourage optimal use of resources and to foster exploration of alternative models of care. EDAP 3.10.1 Establish clear guidelines and timely communication channels RHH leadership High 3 Immediate 3 9 for complex decision making regarding prioritisation of about priorities patients for ICU beds. This should include planning of high risk /policies surgery in both public and nearby private facilities and in discussion of requests for inter‐hospital transfers. (see earlier discussion regarding IT approaches to communication)

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PART A

REVIEW RECOMMENDATIONS BY REVIEW Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility EDAP 3.10.2 Develop a thrombolytic treatment regimen for acute stroke RHH leadership High 3 Immediate 3 9 patients that can be provided in the acute stroke ward and about priorities that does not require mandatory ICU admission /policies EDAP 3.10.3 Consider other treatments that may be safely delivered in RHH leadership High 3 Within 12 2 6 non‐ICU wards with a revised model of care, such as Non‐ about priorities months Invasive Ventilation (NIV) and delivery of high flow oxygen /policies therapy. EDAP 3.10.4 Prioritise improvement work on reducing the delay for Improving patient High 3 Within 12 2 6 transfer of ICU patients to ward beds flow / bed months management EDAP 3.11.1 Shift to a distributive admission model for General Medicine Medical wards / High 3 Immediate 3 9 in which new patients referred to the unit are distributed units evenly across all four teams on a continuous basis to provide a regular predictable and manageable workload for JMO and consultants. EDAP 3.11.2 Develop a model for daily morning consultant review of RHH leadership High 3 Immediate 3 9 inpatients by each team’s consultant about priorities /policies EDAP 3.11.3 Separate MET call registrar responsibility from that of the Medical wards / High 3 Immediate 3 9 acute medical receiving call role as much as possible. units EDAP 3.11.4 Match JMO staff rosters with predictable time of high Medical wards / Moderate 2 Within 12 2 4 workload to improve safety and ensure care progresses 24/7 units months EDAP 3.11.5 Institute week‐on/week‐off longer shift rosters to reduce Medical wards / Moderate 2 Within 12 2 4 handovers and improve accessibility of JMO staff to patients units months and families and ensure staff have meaningful rostered time off with minimal rostered overtime. EDAP 3.11.6 Develop an agreed expectation regarding consistency, timing RHH leadership Moderate 2 Within 12 2 4 and frequency of consultant ward rounding for all services, about priorities months monitored by each interdisciplinary leadership group /policies EDAP 3.11.7 Review the role of the APU to evaluate whether the same Medical wards / Moderate 2 Immediate 3 6 goals could not be met by a simpler, single General Medical units service model situated away from the ED, with strict co‐ location of patients with their managing team (few or no outliers) and effective referral paths to appropriately experienced allied health staff. EDAP 3.11.8 Report weekly performance data designed to ensure Data / Information Moderate 2 Within 12 2 4 investigative and other specialty units provide timely / IT months responses to referrals from inpatients after they have left the ED and arrived in the ward. EDAP 3.11.9 Simplify the referral process for subacute care, rehabilitation Subacute / geriatric High 3 Immediate 3 9 and home‐based services, HITH, Geriatric support at home, etc down to a single number for all referrals with transparent real‐time waiting list management.

EDAP 3.11.10 Develop a hospital‐at‐night program to improve the capability RHH leadership High 3 Within 12 2 6 of wards to safely receive patients overnight, and reduce staff about priorities months stress. This program should facilitate a team approach to /policies shared task management overnight amongst all rostered staff, including some floating nursing staff credentialed for minor procedures (IVC, IDC). Time to task completion, particularly to review of deteriorating patients should be a key KPI. EDAP 3.12.1 Develop a system with appropriate capacity to protect Surgical wards / High 3 Within 12 2 6 elective surgical stream/beds to improve elective surgical units months performance. In the short term this may require greater engagement with private hospitals.

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PART A

REVIEW RECOMMENDATIONS BY REVIEW Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility EDAP 3.12.2 Undertake regular reviews of same day surgery approach to Surgical wards / Moderate 2 Within 12 2 4 ensure international ‘better’ practice. units months EDAP 3.12.3 Develop effective monitoring and escalation processes and a Surgical wards / Moderate 2 Immediate 3 6 “fasting clock” to ensure that inpatients awaiting units theatre/laboratory procedures are not subject to sequential cancellations or prolonged fasting EDAP 3.13.1 RHH and THS work to progress plans to rapidly improve Mental health / High 3 Immediate 3 9 community‐based mental health care as proposed in the services modified Trieste model under development as a primary action to relieve acute access block for mental health patients.

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PART B

REVIEW RECOMMENDATIONS BY CLASSIFICATION: Goal / Vision Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility Staib 2016. 11 Staff updated on evidence that improved flow improves Goal / vision High 3 Immediate 3 9 outcomes. Such shared understanding that the ED‐inpatient interface affects patient outcomes should enhance ED and inpatient team collaboration to focus on improved flow Staib 2016. 13 Patient outcomes must remain at the centre of all care Goal / vision High 3 Immediate 3 9 delivered Monaghan 2012. 1 Addressing the misguided belief that ED is the driver and sole Goal / vision High 3 Immediate 3 9 beneficiary of process reform. Monaghan 2012. 45 The solution to ramping is to enhance movement of patients Goal / vision High 3 Immediate 3 9 through the ED and the greater hospital EDAP 1.1.1 The Secretary of the Department of Health and senior clinical Goal / vision High 3 Immediate 3 9 leaders commit to a vision of a highly integrated health service from the acute through sub‐acute and mental health sectors to the community

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PART B

REVIEW RECOMMENDATIONS BY CLASSIFICATION: Governance / Org structure Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility Commission 2014. 2 Service configuration. Tasmania’s hospitals provide a range of Governance / org Moderate 2 Within 3 1 2 services in relatively low volumes that is typically not structure years matched in hospitals of similar size, function, and location in other parts of Australia. As a consequence, Tasmanians have local access to a broader range of public hospital services than residents of comparable regions. There is a lack of a coherent statewide framework for service provision, with inappropriate duplication of services across multiple organisations. Commission 2014. 4 Funding. The Commonwealth is undertaking considerable Governance / org Low 1 Within 3 1 1 additional investment in the Tasmanian health system under structure years the Tasmanian Health Assistance Package. Governments should take stock of whether all initiatives are well‐targeted to improve the sustainability of the Tasmanian health system. Commission 2014. 5 The new governance arrangements in Tasmania are not Governance / org High 3 Immediate 3 9 functioning in a manner conducive to achieving a sustainable structure health system. There is confusion about roles and responsibilities and a lack of accountability for performance. Commission 2014. 6 Considerable efficiencies, not yet realised in the move Governance / org Moderate 2 Within 12 2 4 towards the devolved DHHS/THO structure, can be gained structure months from improvements in operational management of the Tasmanian health system. Commission 2014. 14 Service planning and reconfiguration. Further consideration Governance / org Moderate 2 Within 3 1 2 of the perceived benefits of regional self‐sufficiency must be structure years balanced with the benefits that can be achieved through increased collaboration across the Tasmanian health system. Commission 2014. 15 That the roles, responsibilities, authorities and lines of Governance / org High 3 Immediate 3 9 accountability across the Tasmanian health system be clearly structure identified, formalised and embedded in a range of available tools, including Ministerial Policy, Ministerial Charters, Service Agreements and performance requirements. Commission 2014. 16 That the THO Governing Councils be reconfigured to oversee Governance / org 0 ## 0 ## 0 the performance of the THO functions consistent with the structure THO Act, Commission 2014. 17 That the existing Performance Framework be accepted and Governance / org Moderate 2 thin 12 mont2 4 embedded across the system, including through Ministerial structure Charters and Service Agreements. Commission 2014. 18 That DHHS review the existing Ministerial Charters to assess Governance / org Low 1 thin 12 mont2 2 the extent to which they have been complied with and what structure sanctions are applied for non‐compliance. Commission 2014. 19 That the Minister issue the endorsed Clinical Governance Governance / org Moderate 2 thin 12 mont2 4 Framework as a Ministerial Policy to prioritise its structure operationalisation across the system, supported by both the State and THO clinical governance committees. Commission 2014. 20 That the Minister endorse DHHS’s establishment of an Governance / org Moderate 2 thin 12 mont2 4 overarching system‐wide Clinical Governance Committee, as structure the peak body for the implementation of the clinical governance framework, including representation from each of the Governing Councils and the TML. Commission 2014. 21 That THOs establish clinical governance committees at the Governance / org High 3 Immediate 3 9 local level to lead and monitor clinical performance, reporting structure to their respective Governing Councils and the overarching system‐wide Clinical Governance Committee.

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PART B

REVIEW RECOMMENDATIONS BY CLASSIFICATION: Governance / Org structure Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility Commission 2014. 22 That the statewide and THO clinical governance committees Governance / org High 3 Immediate 3 9 jointly establish procedures for implementation of system‐ structure wide safety and quality policy, consistent with the national framework promulgated by the Australian Commission 2014. on Safety and Quality in Health Care. Commission 2014. 23 That planning and delivery of both clinical services and Governance / org Moderate 2 thin 12 mont2 4 support services occur within a statewide policy framework, structure through a collaborative process led by DHHS. Commission 2014. 24 That the Minister issue policy directions outlining: a system‐ Governance / org Moderate 2 thin 12 mont2 4 wide vision, strategic direction, and requirements for structure planning and collaboration within the Tasmanian health system; and a statewide Service Capability and Purchasing Policy to guide statewide service planning and delivery. Commission 2014. 25 That the Ministerial Charters be expanded to require each Governance / org 0 ## 0 ## 0 THO Governing Council to submit to DHHS its strategic structure directions on an annual basis, including detail on how the THO will meet its purpose and strategic objectives consistent with Part 2 of the current Ministerial Charters. Commission 2014. 26 That a business case be developed for a shared service entity Governance / org Moderate 2 Within 3 1 2 to provide functions (including but not limited to supplies, structure years equipment, payroll, finance operations, business systems, procurement services, asset management services and a shared information technology system) to DHHS and the THOs, in a cost‐effective, efficient and integrated fashion. This may involve entering into partnership arrangements with other jurisdictions. Commission 2014. 27 That a Health Advisory Council, chaired by the Secretary of Governance / org Moderate 2 Within 12 2 4 DHHS and comprising the THO Governing Council Chair(s), the structure months TML CEO, clinicians and healthcare providers, be established to provide advice to the Minister on statewide service planning and integration. Commission 2014. 28 That the Minister revisit the implementation of new Governance / org Low 1 Within 3 1 1 governance arrangements under the THO Act within the next structure years two years to assess the impact of any corrective action taken and to consider whether legislative change is necessary to achieve the policy intent of the Act. Commission 2014. 29 That DHHS and the THOs ensure that operational Governance / org High 3 Immediate 3 9 management roles, responsibilities and delegations are structure clarified and communicated effectively as a matter of highest priority. Commission 2014. 30 That DHHS and the THOs take responsibility for embedding Governance / org Moderate 2 Within 12 2 4 effective performance management processes within the structure months system. Commission 2014. 32 That DHHS take immediate steps to centralise and reform Governance / org Moderate 2 Within 12 2 4 administrative functions, starting with Payroll and HR structure months services, across DHHS and the THOs. Commission 2014. 33 That the Minister direct the DHHS to immediately lead a Governance / org Moderate 2 Within 3 1 2 systematic review of all the administrative functions of the structure years health system, modelled on HR and Payroll process reviews recently undertaken, to identify and remediate inefficient and out‐of‐date practices. Commission 2014. 34 That the conduct of the review and the implementation of its Governance / org Moderate 2 Within 12 2 4 recommendations be overseen by appropriate governance structure months arrangements, including the involvement of the Tasmanian Department of Treasury and Finance. Implementation will be guided by an agreed plan of action including milestones and key performance indicators.

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PART B

REVIEW RECOMMENDATIONS BY CLASSIFICATION: Governance / Org structure Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility Commission 2014. 35 That a small external panel of population health experts Governance / org Low 1 Within 12 2 2 undertake a review of Population Health Services division of structure months DHHS, with a view to recommending significant reforms involving integration with other services. These reforms should include a process of prioritising key functions and decentralising where possible. Commission 2014. 36 That senior management be given an efficiency dividend to be Governance / org Low 1 Within 12 2 2 achieved through the reform and restructuring arising from structure months the Commission 2014. ’s recommendations on operational efficiency. Commission 2014. 37 That DHHS progress its activities to improve statewide ICT Governance / org High 3 Within 12 2 6 systems as a matter of priority, ensuring that any work structure months undertaken is effective and builds on investments already made in ICT system and network upgrade projects. Commission 2014. 70 That there be recognition that pursuing a high level of Governance / org Moderate 2 Within 12 2 4 regional self‐sufficiency across a range of acute care services structure months is a potential risk to the safety and quality of patient care and impacts upon operational efficiency and system sustainability. Current levels of local acute care provision need to be assessed on this basis. Staib 2016. 3 Patients first initiative is prioritised and progress against Governance / org High 3 Within 12 2 6 previous Monaghan report is measured structure months Staib 2016. 6 Contemporaneous organisational charts for both sites are Governance / org Moderate 2 Immediate 3 6 released structure Staib 2016. 8 Accountability for metrics and the authority to undertake Governance / org High 3 Immediate 3 9 process and policy change are aligned. structure Pt First. 17 Statewide consistent Admissions Policies Governance / org High 3 Within 12 2 6 structure months Pt First. 18 Statewide Clinical Handover Framework Governance / org High 3 Immediate 3 9 structure TAS AG. 1 THS and DoH take urgent action to strengthen whole‐of‐ Governance / org High 3 Immediate 3 9 health system leadership and coordination of initiatives structure designed to improve patient flow by, at a minimum: (a) clarifying the roles and responsibilities of all hospital Executive Directors of Operations, mental health services and primary and community care leadership teams, inpatient wards, department heads, clinicians, nurses and related administrative and support staff in prioritising and contributing to hospital and system‐wide initiatives to improve patient flow TAS AG. 8 THS and DoH review and, where relevant, action outstanding Governance / org High 3 Immediate 3 9 recommendations from the Patients First, Staib Sullivan and structure Monaghan reviews. TAS AG. 9 DoH, in consultation with THS, expedite development of the Governance / org Moderate 2 Within 12 2 4 revised THS Performance Framework. structure months EDAP 1.1.2 Establish a committee charged with implementation of the Governance / org High 3 Immediate 3 9 recommendations of this review together with the structure outstanding high priority, still relevant recommendations of previous reviews (see appendix) within 2 years. This committee should be chaired by the Secretary and include senior hospital administrative and clinical leadership (including Mental health) and community representation. EDAP 1.2.1 Recruitment processes be revised to ensure a nationally Governance / org High 3 Within 12 2 6 competitive, timely and responsive appointment cycle structure months EDAP 1.2.2 Review and minimise the current practice of making short Governance / org High 3 Within 12 2 6 term appointments for clinical staff operational roles. structure months

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PART B

REVIEW RECOMMENDATIONS BY CLASSIFICATION: Governance / Org structure Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility EDAP 1.3.1 Identify where the former board roles to support and appoint Governance / org High 3 Within 12 2 6 the Executive Director of Operations (or equivalent manager), structure months and provide oversight of quality and safety, risk management, strategy, audit, organisational culture, consumer advice and financial responsibility reside in the current THS/DoH structures. Regularly monitor and transparently report on them. EDAP 1.3.2 Adjust the governance of the THS and Northern / Southern Governance / org High 3 Immediate 3 9 hubs by having the senior manager of both the ‘Southern structure Hub’ and the ‘Northern Hub’ on the THS Executive, thus reporting directly to the Secretary. EDAP 1.3.3 Clarify the role of the Senior Executive at the Southern Hub / Governance / org High 3 Immediate 3 9 RHH to ensure that all clinical services including Mental structure Health, ambulatory care and community services are appropriately integrated into the clinical executive structure. EDAP 1.3.5 Introduce a “Good Ward Governance” program in which Governance / org High 3 Immediate 3 9 unit/ward interdisciplinary leadership teams (medical, structure nursing, allied health, pharmacy) meet monthly with a standardised agenda and quality reports, and are responsible at local ward/unit level for reviewing performance, improving patient flow and implementing other improvements as agreed by the hospital clinical leadership executive. EDAP 1.6.2 Strengthen and resource the governance, leadership and Governance / org High 3 Immediate 3 9 capability of health service delivery improvement at RHH, structure with initial focus on improving hospital flow and access. EDAP 3.9.3 Governance and fiduciary responsibility for alternative Governance / org Moderate 2 Immediate 3 6 pathways to inpatient care should reside at least in part structure together with responsibility for subacute care to encourage optimal use of resources and to foster exploration of alternative models of care.

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PART B

REVIEW RECOMMENDATIONS BY CLASSIFICATION: Culture Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility Commission 2014. 11 Changing culture. Poor leadership and bad behaviour is at the Culture High 3 Immediate 3 9 core of Tasmania’s inability to achieve both effective governance and sustainable change. No move to improve the health system will succeed without cultural change. Commission 2014. 60 That the Tasmanian Minister for Health, in his agreements Culture High 3 Immediate 3 9 with the Governing Councils, emphasise his expectation of positive leadership of, and collaboration between, THOs and all clinical stakeholders, including the TML, to drive cultural change. Commission 2014. 61 That senior officials and clinical leaders in the healthcare Culture High 3 Immediate 3 9 system, in fulfilling their roles, be required to conform to the highest degrees of professionalism, honesty and integrity, and act in a manner consistent with the Code of Conduct under section 9 of the State Service Act 2000. Commission 2014. 62 That the Governing Councils make cultural change and Culture High 3 Immediate 3 9 leadership one of their main priorities. Staib 2016. 10 Staff culture survey is released and an operational plan is Culture Moderate 2 Within 12 2 4 completed to address findings months UTAS 6 Review the current state of ‘voice of the staff’ Culture High 3 Within 12 2 6 months TAS AG. 3 THS and DoH urgently implement a culture improvement Culture High 3 Immediate 3 9 program and initiatives with clearly defined goals, accountabilities and timeframes to: (a) eliminate the longstanding dysfunctional silos, attitudes and behaviours within the health system preventing sustained improvements to hospital admission, bed management and discharge practices (b) ensure that all THS departments and staff work collaboratively to prioritise the interests of patients by diligently supporting initiatives that seek to optimise patient flow. EDAP 1.5.2 Hold second‐monthly “Executive Road Shows” open to all Culture High 3 Within 12 2 6 staff in which senior administrative and clinical leaders, and months occasionally system leaders, outline current organisational priorities, performance initiatives and directions for the future. These should be held in a theatre style session with substantial opportunities for ad lib questions from the staff, using an anonymous digital format. EDAP 1.6.1 The Department Secretary commits to, and resources, an Culture High 3 Immediate 3 9 ongoing cultural change program fostering both a “can‐do” culture of continuous improvement in patient outcomes as well as RHH becoming a truly “great place to work”. EDAP 2.1.1 Undertake an educational project for staff designed to Culture Moderate 2 Within 12 2 4 increase understanding of the importance of sharing of risk months across the system. EDAP 3.1.2 Strengthen leadership, capability and governance of health Culture High 3 Within 12 2 6 service delivery improvement science work, aimed at months developing a “can‐do” culture of effective change, with initial focus on improving hospital flow and access.. EDAP 3.8.6 Increase the integration of pharmacists with interdisciplinary Culture Moderate 2 Within 12 2 4 team care at RHH to improve reporting, and reduce months occurrence of, medication errors and foster effective de‐ prescribing practices

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PART B

REVIEW RECOMMENDATIONS BY CLASSIFICATION: Engagement and Empowerment Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility Commission 2014. 9 Clinical engagement. Clinician engagement is pivotal to Engagement and High 3 Immediate 3 9 successful redesign and operation of the Tasmanian health empowerment system. Urgent attention is required to determine the most suitable and sustainable approaches for clinician engagement in the planning and management of the system. Commission 2014. 31 That managers be supported and provided with the Engagement and Moderate 2 Within 12 2 4 appropriate tools to undertake regular and effective empowerment months performance review of all staff, and that this support is also provided to Governing Councils in order that they fulfil their role in relation to CEO and system performance. Commission 2014. 54 That the THO Governing Councils increase clinician Engagement and High 3 Immediate 3 9 involvement in Governing Council meetings to receive empowerment information and advice on health system issues, and to provide their input on clinical governance. Commission 2014. 56 That Clinical Advisory Groups be formed as a priority, with Engagement and High 3 Immediate 3 9 clear and agreed terms of reference; and be utilised empowerment effectively as a conduit between clinicians and administrators.

Commission 2014. 57 That THOs consider implementing the use of clinician Engagement and Moderate 2 Within 3 1 2 compacts as an opportunity to improve engagement between empowerment years a health service and Visiting Medical Officers (VMOs). Commission 2014. 58 That consideration be given to appointing ‘clinical champions’ Engagement and High 3 Within 12 2 6 to: enable the promulgation of best practice and innovation empowerment months (including clinical redesign); and lead the development of collaborative clinical partnerships within and across specialties and sectors. Commission 2014. 63 That an approach to whole‐of‐system leadership training is Engagement and High 3 Within 12 2 6 provided for all managers (clinical and administrative) of the empowerment months health system. This could be delivered through the University of Tasmania, in conjunction with other relevant institutions. Staib 2016. 9 Effective clinical leadership is prioritised at both sites Engagement and High 3 Immediate 3 9 empowerment Staib 2016. 14 ED staff have admitting rights against bilaterally agreed Engagement and High 3 Immediate 3 9 (between inpatient and ED staff) admission guidelines empowerment Monaghan 2012. 2 Implementation of Clinical Pathways. As a matter of urgency, Engagement and High 3 Immediate 3 9 pathways for #NOF, code STEMI, Haematemesis & Melaena, empowerment and Paediatric/Adult Asthma pathways should be implemented Monaghan 2012. 25 The availability of protocols for medical and nursing staff in Engagement and High 3 Immediate 3 9 areas such as streaming to admission or discharge streams empowerment and admission pathways needs to be addressed. Pt First. 16 Recognising the role of clinical leadership Engagement and High 3 Immediate 3 9 empowerment TAS AG. 1B (b) ensuring all hospital, mental health and community care Engagement and High 3 Within 12 2 6 leadership teams, department heads and their staff are fully empowerment months empowered, sufficiently resourced and accountable for achieving sustained improvements in hospital and system‐ wide collaboration and performance on patient flow

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PART B

REVIEW RECOMMENDATIONS BY CLASSIFICATION: Engagement and Empowerment Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility TAS AG. 4 THS and DoH develop an effective sector‐wide consultation Engagement and High 3 Immediate 3 9 and engagement strategy to support sustained improvements empowerment in patient flow that, at a minimum, provides: (a)education to staff on the need for, and merits of, whole‐of‐hospital action to reduce access block through more effective and efficient admission, bed management and discharge practices and the benefits to patient care and safety that come from improved patient flow (b) genuine opportunities for THS staff to contribute to and influence the design, development and implementation of hospital and sector‐wide patient flow reform initiatives. EDAP 1.3.4 Hold the senior clinical leadership accountable for operational Engagement and High 3 Within 12 2 6 efficiency, budgetary, safety and quality portfolios and empowerment months activities that contribute to patient flow within their streams by developing relevant KPIs that are reflected in detailed annual performance reviews. EDAP 1.4.1 RHH should insist that those in leadership positions provide Engagement and High 3 Within 12 2 6 evidence of ongoing professional development in leadership empowerment months and improvement science skills. This should be reflected in position descriptions, job advertisements, job interviews and during annual performance appraisals EDAP 1.4.2 Senior leaders should be given the opportunity of mentored Engagement and High 3 Within 12 2 6 leadership training with appropriate local or national empowerment months agencies. EDAP 1.5.1 Clinical leaders including unit heads and substantial FTE Engagement and High 3 Within 12 2 6 clinical appointees should have non‐clinical support time that empowerment months reflects their responsibilities for portfolios including staff management, safety, quality, improvement/development, education and research duties – up to 0.5 EFT for heads of very large and complex units and 0.2 EFT for other full time appointments. The expectations of these non‐clinical roles should be clearly defined and these staff should be held accountable for their achievements in these portfolios during annual performance reviews. EDAP 1.6.3 Encourage reciprocal staff visits to, and communication with, Engagement and Moderate 2 Within 12 2 4 exemplar hospitals empowerment months

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REVIEW RECOMMENDATIONS BY CLASSIFICATION: Sharing of risk Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility UTAS 25 Ward staff did not appear to be aware of ED workload levels Sharing of risk High 3 Immediate 3 9 and therefore respond accordingly (e.g. ED overcrowding, ambulance ramping) in a manner that alleviated ED patient loads. TAS AG. 2 THS and DoH urgently review the root causes of the growth in Sharing of risk High 3 Immediate 3 9 ED adverse events and implement targeted initiatives to mitigate the impacts and reduce future incidences.

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REVIEW RECOMMENDATIONS BY CLASSIFICATION: Data / Information / IT Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility Commission 2014. 1 Data. A lack of reliable and comparable data, particularly Data / Information High 3 Within 12 2 6 relating to hospital costs, has restricted our ability to draw / IT months definitive conclusions in some areas and is a significant impediment to effective management of the system. Commission 2014. 13 Improving efficiency. Further work is required to improve Data / Information High 3 Within 12 2 6 data quality, but Tasmania appears to have higher hospital / IT months costs, particularly for services with low volumes. Commission 2014. 67 That DHHS, as a matter of urgency, undertake a review to Data / Information High 3 Immediate 3 9 identify and remedy the causes of significant costing data / IT variations. Commission 2014. 68 That DHHS, supported by the Commission 2014. , undertake Data / Information 0 ## 0 ## 0 an audit of data management practices across DHHS and the / IT THOs, funded from Element D of the THAP. Commission 2014. 69 That DHHS, consistent with its role of system oversight, be Data / Information High 3 Within 12 2 6 the steward of a statewide approach to data management. / IT months Staib 2016. 1 Define “timely” and have this definition agreed for each Data / Information High 3 Immediate 3 9 phase of care (ED, inpatient, discharge) / IT Staib 2016. 2 Performance is benchmarked and communicated and data is Data / Information High 3 Within 12 2 6 available to staff to monitor and guide clinical redesign / IT months Staib 2016. 12 A focus on data sharing and patient outcomes rather than just Data / Information High 3 Within 12 2 6 process measures such as time in order to accelerate clinical / IT months engagement Monaghan 2012. 13 There would be value in analysing the most recent bed Data / Information High 3 Within 12 2 6 capacity audit, or repeating an audit to determine what other / IT months initiatives may enhance hospital capacity. Monaghan 2012. 27 The current EDIS program available to the department does Data / Information Moderate 2 Within 12 2 4 not demonstrate increasing LOS in a form that would prompt / IT months activity on patients that were having extended stays within the department. Monaghan 2012. 28 The Hospital Intranet needs to be updated to enable access to Data / Information High 3 Immediate 3 9 relevant, up to date policies and guidelines as currently many / IT policies are outdated and not utilised. Monaghan 2012. 34 That a proforma admission sheet, or an electronic medical Data / Information High 3 Within 12 2 6 record model be considered for improving efficiencies in the / IT months medical clerking process. EDAP 1.9.1 Develop capability to measure data for improvement that Data / Information High 3 Immediate 3 9 monitors for “bottlenecks” to patient flow and that has the / IT capability to identify “qualified” and “non‐qualified” patients (as per MCAPS). EDAP 1.9.2 Further develop and audit the accuracy of integrated Data / Information High 3 Immediate 3 9 reporting systems for safety, performance improvement, / IT quality assurance and risk. EDAP 1.9.3 Develop a process for action on Health Round Table data Data / Information High 3 Within 12 2 6 where there are persistent ‘red flags’: currently areas of / IT months pressure care, length of procedures, use of blood, complications and day surgery activities. EDAP 1.10.1 Develop a digital strategy that includes implementation of a Data / Information High 3 Within 12 2 6 fit for purpose electronic medical record (strategy 12 months, / IT months implementation 4 years). EDAP 1.10.2 Approval of new data systems should in the interim be limited Data / Information Moderate 2 Immediate 3 6 to those that can be effectively integrated with the chosen / IT service. EDAP 1.10.3 Evaluate electronic ordering systems for key diagnostic and Data / Information High 3 Within 12 2 6 service areas keeping in mind eventual requirements for / IT months integration with the EMR.

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REVIEW RECOMMENDATIONS BY CLASSIFICATION: Data / Information / IT Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility EDAP 1.10.4 Improve communications between clinical staff both in and Data / Information Moderate 2 Within 12 2 4 outside the hospital using safe technology that fosters better, / IT months safe decision making (instant messaging and videoconferencing apps) EDAP 3.11.8 Report weekly performance data designed to ensure Data / Information Moderate 2 Within 12 2 4 investigative and other specialty units provide timely / IT months responses to referrals from inpatients after they have left the ED and arrived in the ward.

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REVIEW RECOMMENDATIONS BY CLASSIFICATION: Change Management Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility Commission 2014. 7 Clinical redesign. Clinical redesign is needed to address Change High 3 Within 12 2 6 serious problems with patient access to care and the management months efficiency of clinical and administrative practices. The success of the redesign program will be highly dependent on leadership and buy‐in at all levels—from the Minister, THO Governing Councils and executives, and clinicians—and a commitment to a consistent and rigorous approach to identifying priorities. Commission 2014. 38 That THO Governing Councils and CEOs take responsibility for Change High 3 Within 12 2 6 driving a culture for clinical redesign that is systematic, uses a management months consistent and rigorous methodology, and focuses on statewide priorities. Commission 2014. 39 That the University of Tasmania engage external expertise to Change 0 ## 0 ## 0 mentor and support managers and clinicians in building management clinical redesign capacity and to assist it in the development of its clinical redesign training program. Commission 2014. 40 That priority be given in the establishment phase of the Change High 3 Immediate 3 9 clinical redesign program to the following areas: developing management robust governance arrangements; establishing program leadership; undertaking comprehensive stakeholder engagement and building an understanding of clinical redesign throughout the system; establishing Clinical Lead positions in THOs and connecting with the TML Health Pathways positions; providing additional support and mentoring in redesign methodology; determining priority areas for redesign focus and investment through a rigorous statewide diagnostic process; developing a Strategic Plan for work over the longer term; and building strategic alliances with clinical redesign experts.

Commission 2014. 55 That the development and implementation of a clear process Change Moderate 2 Within 12 2 4 for clinical handover for Tasmania be undertaken. This should management months involve working closely with clinicians, the TML, THOs and other key stakeholders in the health system.

Commission 2014. 64 That clinical and administrative leaders of the three THOs and Change High 3 Within 12 2 6 DHHS strengthen their strategic capability in change management months management by participating in appropriate performance development. Commission 2014. 65 That the three THOs and DHHS implement a well‐planned Change High 3 Within 12 2 6 change management process, including actively seeking staff management months engagement at all levels through a program of regular staff consultation. Staib 2016. 5 Excellent clinical redesign already underway is encouraged Change Moderate 2 Within 12 2 4 management months UTAS 2 Redesign patient flow processes and systems. Change High 3 Within 12 2 6 management months UTAS 3 Redesign ward length of stay management and discharge Change High 3 Immediate 3 9 planning practices. management UTAS 7 Ensure a robust change management strategy appends the Change High 3 Immediate 3 9 broader redesign programs. This should be inclusive of a management definitive communications strategy across the organisation, stakeholder engagement plan and hospital wide change plan.

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REVIEW RECOMMENDATIONS BY CLASSIFICATION: Change Management Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility Pt First. 3 Transparent, published principles for ED Care: On arrival to Change High 3 Immediate 3 9 ED, all patients will be seen within 30 minutes by a member management of a consultant‐led, interdisciplinary team who will initiate assessment, investigations and treatment; Patients will be discharged from the ED or admitted to the hospital as decided by the ED consultant staff; Patients will be reviewed by an inpatient team within two hours of arrival on a ward; Patients will be admitted to a bed in the most appropriate clinical place, first time; Patients will have investigations, consultations and interventions completed as soon as possible, in order of request or clinical priority and where practical within 24/24; Patients will be reviewed daily by a decision‐making clinician in collaboration with the patient/carer; Hospital resources, including human resources, will be allocated according to system priorities based upon accurate data; Working hours and rosters for front line clinicians will be managed to ensure staff are available when required to ensure safe patient care; Patients will be cared for in the facility most appropriate to their current clinical need ensuring they are only in hospital for as long as clinically necessary. TAS AG. 7 THS and DoH review and strengthen the: (a)change Change High 3 Within 12 2 6 management capability and skills of THS and hospitals to management months ensure future reform initiatives are adequately supported and deliver sustained behaviour change and impact (b) project management capability of THS and hospitals to ensure future reform initiatives are underpinned by effective implementation and delivery planning processes that are regularly monitored. EDAP 1.7.1 Acknowledge that, despite pockets of excellence, change Change High 3 Immediate 3 9 management across the system has a very poor recent record management and requires serious and systematic attention. EDAP 1.7.2 The THS/DoH enlist the help of a capable external agency (eg Change High 3 Within 12 2 6 IHI) to support RHH for the next 2‐3 years to both implement management months a change management program focussed on improving patient flow and also to develop local skills and capability for future change. Opportunities for collaboration with interstate agencies should be explored. EDAP 1.7.3 That change management to improve patient flow should Change High 3 Within 12 2 6 extend outside the hospital to the development of responsive management months community‐based healthcare services with funding models that incentivise these changes. EDAP 3.1.4 Develop a single coordinated unit working between the Change High 3 Within 12 2 6 hospital and community to progress programs that reduce management months patient presentations and can deliver specialised nursing services and hospital specialty opinions in the community EDAP 3.1.5 Develop funding models to incentivise hospitals to use them. Change High 3 Within 12 2 6 management months

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REVIEW RECOMMENDATIONS BY CLASSIFICATION: Improving patient flow / Bed management Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility Monaghan 2012. 6 The order of priority of bed allocation for different areas such Improving patient High 3 Immediate 3 9 as APU, ED and elective surgery needs review. flow / bed management Monaghan 2012. 9 The benefits of a well utilized Transit Lounge for enhancing Improving patient High 3 Immediate 3 9 discharge practice are well documented. It will be important flow / bed to think about improving access to this area in expectation of management completion of the capital works. Monaghan 2012. 10 Suggest that the ED CNS or NUM could attend Patient Flow Improving patient High 3 Immediate 3 9 meetings in order to create rapport between ED and the flow / bed wards especially given the ward NUMs attendance. management Monaghan 2012. 11 The role of the after‐hours Patient Flow Manager and role Improving patient High 3 Immediate 3 9 consistency need to be addressed because it impacts on flow / bed timely patient access to beds from ED. management Monaghan 2012. 12 Improved communication between ED and bed management, Improving patient 0 ## 0 ## 0 including review of the process of notifying ED of bed flow / bed allocations. management Monaghan 2012. 14 Implement and enforce a safe, consistent admissions policy Improving patient High 3 Immediate 3 9 that allows patients to move safely from ED to the wards, flow / bed without unnecessary delay including always needing to have management inpatient review in ED. Monaghan 2012. 15 Review of the current practice of holding short stay paediatric Improving patient Moderate 2 Immediate 3 6 admissions in ED rather than sending them to the children’s flow / bed ward. management Monaghan 2012. 16 The current common practice of waiting on the full workup of Improving patient High 3 Immediate 3 9 the patient and the admission team’s review prior to flow / bed requesting a bed needs to cease. management Monaghan 2012. 18 Addressing the structure and policy around bed booking slips Improving patient Moderate 2 Within 12 2 4 and redesigning the current form to include more relevant flow / bed months patient history and current clinical requirements. management Monaghan 2012. 21 We would recommend a change to the nursing patient flow Improving patient High 3 Immediate 3 9 position that is currently in place. To counter the problems of flow / bed inconsistency and potentially junior staff within the role, we management would suggest that this role be changed to a substantive position, Monaghan 2012. 35 The current situation of bed availability occurring after 1300‐ Improving patient High 3 Immediate 3 9 1400hrs each day is unacceptable. The solution to this comes flow / bed from many of the initiatives already mentioned in the management recommendations above. UTAS 8 Undertake site visits to high performing organisations across Improving patient High 3 Within 12 2 6 Australia of similar size and complexity. flow / bed months management UTAS 9 Review and implement ward leadership and flow Improving patient High 3 Immediate 3 9 management training. flow / bed management UTAS 19 Review the medical patient journey from admission decision, Improving patient High 3 Immediate 3 9 bed request and bed ready. flow / bed management UTAS 20 There was notable variation in the performance across wards Improving patient High 3 Immediate 3 9 in terms of discharge requirements, planning, and flow / bed destination. management

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REVIEW RECOMMENDATIONS BY CLASSIFICATION: Improving patient flow / Bed management Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility UTAS 21 Key qualitative conclusions in this section are: Improving patient High 3 Immediate 3 9 1. There was strong evidence of empty beds across the flow / bed hospital which ward staff were unsure of who the next management patient allocated to those beds. 2. There was a cohort of patients who were occupying beds whilst waiting for non‐clinical steps which was indicative of a lack of patient journey planning. 3. There was a large cohort of patients who were occupying beds for non‐acute clinical reasons therefore contributing to latent capacity in the hospital (i.e. discharge requirements, discharge destination, discharge planning, and transfer of care). UTAS 22 It was noted that there was a high patient outlier rate across Improving patient High 3 Immediate 3 9 the hospital with an inconsistent management approach. flow / bed management UTAS 23 The bed meeting appeared to lack a focus on resolving ED Improving patient High 3 Immediate 3 9 over‐crowding. flow / bed management UTAS 24 There is variability in management practices and priority with Improving patient High 3 Immediate 3 9 respect to patient flow and length of stay management at a flow / bed ward level covering nursing and medical staff. management

UTAS 27 Accountability and responsibility for patient flow through the Improving patient High 3 Immediate 3 9 wards was unclear in terms of “who is running the hospital” flow / bed on a minute by minute, hour by hour and day by day management operational basis. Pt First. 6 More efficient discharge Improving patient High 3 Immediate 3 9 flow / bed management Pt First. 7 Better Discharge Planning Improving patient High 3 Immediate 3 9 flow / bed management Pt First. 14 Support for very long stay patients Improving patient High 3 Immediate 3 9 flow / bed management Pt First. 19 Any other measures to improve patient flow Improving patient Moderate 2 Within 12 2 4 flow / bed months management TAS AG. 1C (c) taking immediate steps to review and, where relevant, Improving patient High 3 Immediate 3 9 strengthen the effectiveness of coordination mechanisms flow / bed between all departments and staff within hospitals and with management mental health, primary and community care services for optimising patient flow. TAS AG. 5 THS and DoH expedite the development and implementation Improving patient High 3 Within 12 2 6 of proactive strategies that effectively leverage the insights of flow / bed months the 2017 Clinical Utilisation Study to both reduce and management minimise the incidence of avoidable admissions and non‐ qualified continuing days of stay for admitted patients.

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REVIEW RECOMMENDATIONS BY CLASSIFICATION: Improving patient flow / Bed management Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility TAS AG. 10 DoH, in consultation with THS, strengthen performance Improving patient Moderate 2 Within 12 2 4 monitoring and reporting processes to ensure they: flow / bed months (a)provide actionable insights into the root causes of management performance issues affecting ED access and care (b) ensure related improvement actions address the root causes of performance issues and are likely to succeed (c) rigorously assess the merits of alternative escalation/improvement actions in circumstances of consistent underperformance.

EDAP 3.8.1 Ensure the IOC acts to connect relevant staff and oversee Improving patient High 3 Immediate 3 9 effective patient flow across the system. flow / bed management EDAP 3.8.2 Monitor and routinely report on “right patient, right bed”; the Improving patient High 3 Immediate 3 9 percentage of patients in each team’s correct geography to flow / bed encourage colocation of patients in the correct beds, management minimise outliers, and foster interdisciplinary teamwork.

EDAP 3.8.8 Develop ward rounding checklists that include safety and Improving patient Moderate 2 Immediate 3 6 quality items (status of intravenous lines, urinary catheters, flow / bed goals of care and estimated date of discharge) for use in daily management morning ward rounds. EDAP 3.8.9 Institute ward‐based afternoon board rounds (eg 4 pm) with Improving patient Moderate 2 Immediate 3 6 medical and nursing decision makers to plan all aspects of flow / bed early discharges the following morning. management EDAP 3.9.2 As part of “Good Ward Governance” for all wards that refer Improving patient Moderate 2 Immediate 3 6 frequently to subacute care, mandate daily interdisciplinary flow / bed discussions about all patients who potentially require that management care. These discussions should include input from staff knowledgeable about subacute care and its non‐inpatient alternatives. On every occasion these meetings should be attended by senior acute medical decision makers and preferably also subacute representatives.

EDAP 3.10.4 Prioritise improvement work on reducing the delay for Improving patient High 3 Within 12 2 6 transfer of ICU patients to ward beds flow / bed months management

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REVIEW RECOMMENDATIONS BY CLASSIFICATION: Alternatives to ED presentation Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility EDAP 3.1.6 Implement suitable models of care to facilitate provision of Alternatives to ED Moderate 2 Within 12 2 4 hospital‐based advice and specialty opinions to support presentation months nursing or medical staff visiting patients outside the hospital (including user friendly videoconferencing). EDAP 3.2.1 Reduce ambulance arrivals: Continue work on primary and Alternatives to ED Moderate 2 Within 12 2 4 secondary triage to deliver care at appropriate community presentation months resources rather than in the ED EDAP 3.2.2 Understand the processes that link patient transport to Alternatives to ED Moderate 2 Within 12 2 4 ambulance attendance to ensure that transport to the ED is presentation months only required when clinically indicated and only after other appropriate options for client management are found to be unavailable EDAP 3.2.3 Work to change community perceptions regarding ambulance Alternatives to ED Moderate 2 Within 12 2 4 utilisation. presentation months EDAP 3.2.4 Review the overcapacity protocol to consider patients whose Alternatives to ED Moderate 2 Within 12 2 4 arrival has been notified by ambulance services to the ED to presentation months be the responsibility of the hospital.

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REVIEW RECOMMENDATIONS BY CLASSIFICATION: ED Department Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility Monaghan 2012. 3 Reviewing the clinical justification of the GOC and ADDS ED department Moderate 2 Within 12 2 4 Forms’ application to every adult patient, which anecdotally months delays some transfers from ED to the ward. Monaghan 2012. 4 Requests for increasing FTE without associated redesign of ED department Moderate 2 Within 12 2 4 processes are unlikely to provide significant benefit from a months productivity perspective. Monaghan 2012. 17 We would also suggest that the department consider a 2,1,1 ED department High 3 Immediate 3 9 time guide rather than 1,2,1. Two hours for ED review, stabilization, referral and bed booking, one hour for inpatient review, and one hour for movement to the ward.

Monaghan 2012. 19 The transfer policy, which relates to whether patients require ED department High 3 Immediate 3 9 a nurse escort, has been in place since October 2010 but not adhered to. Monaghan 2012. 20 The ED SSU is currently inadequate, and needs to be larger, ED department Moderate 2 Within 12 2 4 with dedicated medical staffing, and appropriate level nursing months staffing to safely accommodate monitored patients when required. Monaghan 2012. 22 The issues around identifying nursing or medical staff ED department Moderate 2 Immediate 3 6 responsible for a particular patient in ED could be quickly sorted by a mandatory, brief “huddle” of nursing and medical staff in their respective areas at the start of each shift.

Monaghan 2012. 23 The observation that there were FACEMs within the ED department Moderate 2 Immediate 3 6 department who did not participate actively in enhancing patient flow raises the question of whether there is still significant work to be done to engage this group. Monaghan 2012. 24 The current situation of lack of KPIs around ED processes ED department High 3 Within 12 2 6 needs to be corrected, and these then need to be used to months identify process inefficiencies within the ED. We suspect there are areas of inefficiency in the ED that are not currently recognizable without mapping and data. Monaghan 2012. 26 Review the current ED nursing/medical reviews, which ED department High 3 Within 12 2 6 presently result in repetition of pt. assessments. months Monaghan 2012. 36 A 24‐ hour radiographer service be created for ED as a matter ED department High 3 Within 12 2 6 of urgency. months Monaghan 2012. 37 The current process of obtaining a plain film in the ED be ED department Moderate 2 Within 12 2 4 reviewed and leaned down. months Monaghan 2012. 38 The installation of a PACS screen in ED was highlighted as a ED department Moderate 2 Within 12 2 4 possibility to improve access to imaging results. months Monaghan 2012. 39 Data to be collected to inform a case for ultrasound and ED department High 3 Within 12 2 6 possibly CT regular slots to be made available for the ED. months Monaghan 2012. 41 A simple solution to be implemented in ED, such as laminated ED department Low 1 Immediate 3 3 signs to identify patients who are booked for ultrasound, to minimize inadequate preparation resulting in cancelled procedures. Monaghan 2012. 44 The option of “removing ramping”, by letting the patients be ED department High 3 Immediate 3 9 dropped off by an ambulance crew into an overcrowded department, is in our opinion never an option.

UTAS 10 Review ED staffing profiles. ED department Moderate 2 Within 12 2 4 months UTAS 13 Review and implement ED team‐based care and patient ED department High 3 Immediate 3 9 streaming. UTAS 14 Review and implement the ED Navigator role. ED department Moderate 2 Immediate 3 6 UTAS 16 Review the current nurse escort and transfer policy. ED department Moderate 2 Immediate 3 6

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REVIEW RECOMMENDATIONS BY CLASSIFICATION: ED Department Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility UTAS 18 Review EMU. ED department High 3 Immediate 3 9 Pt First. 1 A list of unacceptable ‘red flag’ events in Tasmanian Health ED department High 3 Immediate 3 9 Service (THS) Emergency Departments (EDs) Pt First. 4 Clinical Initiative Emergency Nurses ED department Moderate 2 Within 12 2 4 months EDAP 3.5.1 Increase available spaces in the ED and model of care to ED department High 3 Immediate 3 9 support reduction of the transit time for non‐admitted patients and create a high performance 4h KPI for this non‐ admitted patient group. EDAP 3.5.2 Minimise triage time and detail to facilitate rapid streaming ED department Moderate 2 Immediate 3 6 to a senior clinical decision maker who will commence their care in the most appropriate space. EDAP 3.5.3 Collect only a minimum data set at initial patient registration ED department High 3 Immediate 3 9 in ED, completing the collection once a patient’s care has been initiated

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REVIEW RECOMMENDATIONS BY CLASSIFICATION: RHH leadership about priorities / policies Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility Staib 2016. 4 The case for a short stay unit (SSU) at LGH be considered in RHH leadership Moderate 2 Within 12 2 4 the light of accurate data including the potential impact on about priorities months inpatient admissions and NEAT performance, but most /policies importantly, the current numbers of patients who would benefit from SSU care Staib 2016. 15 Escalation procedures are implemented in a timely manner in RHH leadership High 3 Immediate 3 9 order to pre‐empt access block about priorities /policies Monaghan 2012. 5 As there will be an activity shift to the inpatient areas RHH leadership Moderate 2 Within 12 2 4 especially in after hours and acute units investing in staffing about priorities months for these areas will be necessary. /policies Monaghan 2012. 8 The development of a mechanism to alert the hospital to ED RHH leadership High 3 Within 12 2 6 overcrowding and a Ramping response, and a practical about priorities months hospital escalation policy /policies Monaghan 2012. 29 Review the effectiveness of the current Escalation Tool RHH leadership High 3 Immediate 3 9 relating to ED overcrowding. about priorities /policies Monaghan 2012. 40 A tiered approach be considered for prioritizing radiology RHH leadership Moderate 2 Within 12 2 4 access throughout the hospital, with an emphasis on about priorities months availability for acute and critical care areas. /policies Monaghan 2012. 42 Have a pre‐ramping policy and ramping policy, at the very RHH leadership High 3 Within 12 2 6 least to create a consistent response to the situation. about priorities months /policies UTAS 1 Implement (modify if required) a hospital admissions policy. RHH leadership High 3 Immediate 3 9 Review the current admission decision process in ED. about priorities /policies UTAS 11 Review imaging services. RHH leadership Moderate 2 Within 12 2 4 about priorities months /policies UTAS 12 Review hospital operations escalations (predictive and RHH leadership High 3 Immediate 3 9 reactive). about priorities /policies UTAS 15 Review bed flexing practices (ICU/HDU). RHH leadership High 3 Within 12 2 6 about priorities months /policies UTAS 26 There appeared to be a significant disconnect between the RHH leadership High 3 Immediate 3 9 published hospital escalation policy and the hospital wide and about priorities executive response to ED over‐crowding, ward LOS /policies management and overall bed management. Pt First. 2 Evidence based escalation policies RHH leadership High 3 Immediate 3 9 about priorities /policies Pt First. 8 Winter Illness Strategies RHH leadership High 3 Immediate 3 9 about priorities /policies Pt First. 10 Timely Discharge Summaries RHH leadership Moderate 2 Immediate 3 6 about priorities /policies TAS AG. 6 THS strengthen support to, and the accountability of, health RHH leadership High 3 Immediate 3 9 system leadership teams for improving their performance in about priorities sustainably reducing the rate of avoidable admissions and /policies non‐qualified continuing days of stay for admitted patients.

EDAP 1.6.4 Barriers to improvement based on arguments of “clinician RHH leadership High 3 Immediate 3 9 autonomy” need to be immediately called out for what they about priorities are so that better patient outcomes become the first priority. /policies

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REVIEW RECOMMENDATIONS BY CLASSIFICATION: RHH leadership about priorities / policies Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility EDAP 3.3.1 Inter‐hospital patient transfers: Develop an agreed inter‐ RHH leadership Moderate 2 Within 12 2 4 hospital transfer policy that clearly identifies responsibilities about priorities months of the receiving and transferring units/hospitals regarding /policies acceptance and timely return of patients.

EDAP 3.4.1 Ensure Ambulatory care services receive appropriate RHH leadership Moderate 2 Within 12 2 4 representation and improvement focus at hospital executive about priorities months level meetings so that clinics provide timely access for /policies referrals from the community and help relieve hospital access block. EDAP 3.5.4 Implement and monitor performance of the previously RHH leadership High 3 Within 12 2 6 agreed “Timely Quality Care” principles including ED about priorities months consultant authority to admit the patient on interim orders /policies without prior unit review. EDAP 3.5.5 Establish an agreed escalation protocol for unacceptable RHH leadership Moderate 2 Within 12 2 4 delays by inpatient staff responding to requests for opinion about priorities months or notification of admissions by the ED staff. Measure these /policies delays in order to identify the most important opportunities for improvement. EDAP 3.5.6 Implement systems where JMO availability to respond when RHH leadership Moderate 2 Immediate 3 6 referred patients by the ED is maintained even in the setting about priorities of clinic, theatre and ward rounding responsibilities. /policies EDAP 3.6.1 RHH and ED management should review annually: RHH leadership Moderate 2 Within 12 2 4 Allied health resourcing and level of experience to ensure about priorities months best possible, timely decision making for the ED and the EMU. /policies Modelling of EMU bed numbers and usage to ensure they are optimally improving overall organisational flow. Staff orientation/education to ensure all staff have a working knowledge of available admission diversion models and referral pathways.

EDAP 3.7.1 Review and redesign consultant and JMO staffing and rosters RHH leadership High 3 Immediate 3 9 to facilitate progression of patient care in and out of hours about priorities and across weekends and ensure a realistic workload with /policies minimum overtime. EDAP 3.7.2 Establish agreed protocols (minimum order sets) for the most RHH leadership High 3 Immediate 3 9 common clinical reasons for admission between the ED and about priorities inpatient teams so that all have confidence all necessary tests /policies will be initiated in the ED and completed in a timely manner regardless of when the patient is transferred to the ward.

EDAP 3.7.3 For patients in the ward, set tight, transparent KPIs to RHH leadership High 3 Immediate 3 9 minimise delays between ordering and completion of about priorities investigations and referrals found to be most important to /policies the progression of care so that staff are confident they will occur in a timely manner even after the patient has left the ED. EDAP 3.8.3 Develop a process to achieve tight KPIs for bed “turnaround” RHH leadership High 3 Immediate 3 9 times, especially isolation cleans. about priorities /policies EDAP 3.8.4 When there is capacity, the IOC should further develop an RHH leadership Moderate 2 Within 12 2 4 admission flex bed model in which beds staffed for a single about priorities months nursing shift are opened at predicted times of peak demand /policies for egress from the ED. These beds should be available in the most likely destination ward to improve correct geography.

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PART B

REVIEW RECOMMENDATIONS BY CLASSIFICATION: RHH leadership about priorities / policies Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility EDAP 3.8.5 Ensure consistent use of the utilisation of the ‘Paris’ patient RHH leadership Moderate 2 Within 12 2 4 risk screening tool or similar at RHH. about priorities months /policies EDAP 3.8.7 Improve the timely provision of discharge summaries to GPs RHH leadership Moderate 2 Immediate 3 6 and other specialists to improve quality of discharge planning about priorities and minimise the risk of readmission. /policies EDAP 3.9.1 Develop a simple criterion‐based process, agreed between RHH leadership High 3 Immediate 3 9 acute and subacute staff, that allows acute staff to initiate about priorities electronic referral and acceptance of patients to subacute /policies care that also enhances appropriateness of referral. EDAP 3.10.1 Establish clear guidelines and timely communication channels RHH leadership High 3 Immediate 3 9 for complex decision making regarding prioritisation of about priorities patients for ICU beds. This should include planning of high risk /policies surgery in both public and nearby private facilities and in discussion of requests for inter‐hospital transfers. (see earlier discussion regarding IT approaches to communication)

EDAP 3.10.2 Develop a thrombolytic treatment regimen for acute stroke RHH leadership High 3 Immediate 3 9 patients that can be provided in the acute stroke ward and about priorities that does not require mandatory ICU admission /policies EDAP 3.10.3 Consider other treatments that may be safely delivered in RHH leadership High 3 Within 12 2 6 non‐ICU wards with a revised model of care, such as Non‐ about priorities months Invasive Ventilation (NIV) and delivery of high flow oxygen /policies therapy. EDAP 3.11.2 Develop a model for daily morning consultant review of RHH leadership High 3 Immediate 3 9 inpatients by each team’s consultant about priorities /policies EDAP 3.11.6 Develop an agreed expectation regarding consistency, timing RHH leadership Moderate 2 Within 12 2 4 and frequency of consultant ward rounding for all services, about priorities months monitored by each interdisciplinary leadership group /policies

EDAP 3.11.10 Develop a hospital‐at‐night program to improve the capability RHH leadership High 3 Within 12 2 6 of wards to safely receive patients overnight, and reduce staff about priorities months stress. This program should facilitate a team approach to /policies shared task management overnight amongst all rostered staff, including some floating nursing staff credentialed for minor procedures (IVC, IDC). Time to task completion, particularly to review of deteriorating patients should be a key KPI.

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PART B

REVIEW RECOMMENDATIONS BY CLASSIFICATION: Medical wards / units Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility Staib 2016. 7 A structure be considered for inpatient services, particularly Medical wards / 0 ## 0 ## 0 Medicine and Surgery, that facilitates streamlining and units consistency of the ED‐inpatient interface Monaghan 2012. 7 Review of the current practice whereby APU patients Medical wards / High 3 Immediate 3 9 admitted in ED overnight can’t go to APU after 0800hrs and units instead wait in ED for a ward bed. Monaghan 2012. 30 The flow of subspecialty patients through the APU during Medical wards / High 3 Within 12 2 6 standard working hours be reconsidered, as this seems to units months offer very little additional value to patient care. Monaghan 2012. 31 The APU in our opinion needs 24 hour registrar cover, with a Medical wards / High 3 Immediate 3 9 second registrar available to cover the wards after hours. units Monaghan 2012. 32 APU access to radiology is problematic; a possible solution Medical wards / Moderate 2 Immediate 3 6 would be to allow APU to use ED orderlies and the ED units radiology department given their close proximity rather than needing to use the upstairs radiology department. Monaghan 2012. 33 It is clear that for all staff involved, the conflict within the Medical wards / High 3 Immediate 3 9 medical division in terms of the direction the APU model will units take needs to be resolved as early as possible. UTAS 17 Review APU. Medical wards / High 3 Immediate 3 9 units EDAP 3.11.1 Shift to a distributive admission model for General Medicine Medical wards / High 3 Immediate 3 9 in which new patients referred to the unit are distributed units evenly across all four teams on a continuous basis to provide a regular predictable and manageable workload for JMO and consultants. EDAP 3.11.3 Separate MET call registrar responsibility from that of the Medical wards / High 3 Immediate 3 9 acute medical receiving call role as much as possible. units EDAP 3.11.4 Match JMO staff rosters with predictable time of high Medical wards / Moderate 2 Within 12 2 4 workload to improve safety and ensure care progresses 24/7 units months

EDAP 3.11.5 Institute week‐on/week‐off longer shift rosters to reduce Medical wards / Moderate 2 Within 12 2 4 handovers and improve accessibility of JMO staff to patients units months and families and ensure staff have meaningful rostered time off with minimal rostered overtime. EDAP 3.11.7 Review the role of the APU to evaluate whether the same Medical wards / Moderate 2 Immediate 3 6 goals could not be met by a simpler, single General Medical units service model situated away from the ED, with strict co‐ location of patients with their managing team (few or no outliers) and effective referral paths to appropriately experienced allied health staff.

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PART B

REVIEW RECOMMENDATIONS BY CLASSIFICATION: Surgical wards / units Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility Commission 2014. 3 System performance. Alarmingly high numbers of overdue Surgical wards / High 3 Immediate 3 9 patients on elective surgery waiting lists and high rates of units access block and GP‐type presentations in emergency departments require urgent attention. Commission 2014. 8 Management of elective surgery. Tasmania is not prioritising Surgical wards / Moderate 2 Within 12 2 4 elective surgery patients sensibly or transparently and many units months patients are waiting far too long for surgery. There needs to be a systematic approach to elective surgery categorisation and management; efficiency in theatre utilisation; utilisation of private sector capacity; and appropriate role delineation for where surgery is performed.

Commission 2014. 41 That, as a matter of urgency, THOs introduce a more Surgical wards / Moderate 2 Within 12 2 4 systematic approach to elective surgery categorisation and units months management. This should include mechanisms to prioritise the provision of surgery to overdue patients, such as adopting a ‘treat in turn’ policy for scheduling surgery other than for reasons of clear clinical need. Commission 2014. 42 That DHHS and the THOs monitor and report on the Surgical wards / Moderate 2 Within 12 2 4 proportion of ‘treat in turn’ surgery in a consistent and units months transparent way. Commission 2014. 43 That commitment be made to a longer‐term Elective Surgery Surgical wards / Moderate 2 Within 12 2 4 Plan for Tasmania that goes beyond annual budget cycles and units months is cost‐effective and sustainable. Commission 2014. 44 That Tasmania, through the University of Tasmania’s Clinical Surgical wards / 0 ## 0 ## 0 Redesign Program, commit to a diagnostic analysis across the units continuum of surgery management to identify where improvements and efficiencies can be made within the system, including: developing models to separate elective and emergency surgery, initially through a demand/capacity matching analysis for each stream; and analysing theatre management to identify impediments to efficiency and patient flow. Commission 2014. 45 That funding be made available under Element D of the Surgical wards / 0 ## 0 ## 0 Tasmanian Health Assistance Package (THAP) for a specific units focus on elective surgery redesign. Commission 2014. 47 That the THO Governing Councils set goals to substantially Surgical wards / Moderate 2 Within 12 2 4 improve elective surgery waiting list management and reduce units months the rate of elective surgery postponements. Commission 2014. 48 That the process for managing patients on the elective Surgical wards / Moderate 2 Within 12 2 4 surgery waiting list be refined to ensure that practices are units months equitable, transparent and consistent across the state Commission 2014. 49 That DHHS ensure a standard approach to elective surgery Surgical wards / Moderate 2 Immediate 3 6 categorisation as an immediate priority, based on the advice units of the Tasmanian Statewide Surgical Services Committee

Commission 2014. 50 That DHHS lead a collaborative process to develop a surgical Surgical wards / Moderate 2 Within 12 2 4 pathway for patients that maps demand and identifies units months alternative models of patient care. Commission 2014. 51 That a diagnostic analysis be undertaken to review the high Surgical wards / Moderate 2 Within 12 2 4 level of hospital‐initiated postponements, and that service units months redesign requirements be identified and implemented. Commission 2014. 52 That DHHS develop a safe, efficient and viable framework for Surgical wards / Moderate 2 Within 12 2 4 the delivery of surgical services at both statewide and local units months service levels.

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PART B

REVIEW RECOMMENDATIONS BY CLASSIFICATION: Surgical wards / units Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility Commission 2014. 53 That DHHS consider undertaking an external, independent Surgical wards / Moderate 2 Within 12 2 4 review of Tasmanian surgical mortality data, including audit units months data collected through the Tasmanian Audit of Surgical Mortality. EDAP 3.12.1 Develop a system with appropriate capacity to protect Surgical wards / High 3 Within 12 2 6 elective surgical stream/beds to improve elective surgical units months performance. In the short term this may require greater engagement with private hospitals. EDAP 3.12.2 Undertake regular reviews of same day surgery approach to Surgical wards / Moderate 2 Within 12 2 4 ensure international ‘better’ practice. units months EDAP 3.12.3 Develop effective monitoring and escalation processes and a Surgical wards / Moderate 2 Immediate 3 6 “fasting clock” to ensure that inpatients awaiting units theatre/laboratory procedures are not subject to sequential cancellations or prolonged fasting

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PART B

REVIEW RECOMMENDATIONS BY CLASSIFICATION: Mental health / services Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility Pt First. 5 Psychiatric Emergency Nurses Mental health / Moderate 2 Immediate 3 6 services EDAP 3.1.8 For Mental Health patients, resource CAT and other Mental health / High 3 Immediate 3 9 community‐based MH teams to provide timely and ongoing services care in the community supported by MH consultant opinion (e.g. videoconference) to minimise transfers to the ED for patients at risk of a crisis. EDAP 3.13.1 RHH and THS work to progress plans to rapidly improve Mental health / High 3 Immediate 3 9 community‐based mental health care as proposed in the services modified Trieste model under development as a primary action to relieve acute access block for mental health patients.

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PART B

REVIEW RECOMMENDATIONS BY CLASSIFICATION: Subacute / geriatric Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility EDAP 3.1.3 Improve access to outreach/care coordination and other Subacute / geriatric High 3 Within 12 2 6 community‐based services especially for patients in months residential care and patients in their own private residences with frailty or multiple complex chronic disease.

EDAP 3.1.7 Foster discussions with residential aged care services Subacute / geriatric Moderate 2 Immediate 3 6 regarding advanced care plan completion and adherence so there is clear understanding whether or not patients desire transfer to hospital in the event of acute deterioration.

EDAP 3.5.7 Schedule daily consultant geriatrician rounds through ED and Subacute / geriatric High 3 Immediate 3 9 EMU to facilitate admission diversion plans for complex elderly patients and upskill ED staff on alternative pathways of care. EDAP 3.11.9 Simplify the referral process for subacute care, rehabilitation Subacute / geriatric High 3 Immediate 3 9 and home‐based services, HITH, Geriatric support at home, etc down to a single number for all referrals with transparent real‐time waiting list management.

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PART B

REVIEW RECOMMENDATIONS BY CLASSIFICATION: Rehabilitation Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility

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PART B

REVIEW RECOMMENDATIONS BY CLASSIFICATION: Palliative Care Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility

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PART B

REVIEW RECOMMENDATIONS BY CLASSIFICATION: Number of beds Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility Commission 2014. 12 Infrastructure. Major infrastructure investment, particularly Number of beds Moderate 2 Within 12 2 4 the Royal Hobart Hospital redevelopment, has not been months sufficiently informed by whole‐of‐system planning and system sustainability. Commission 2014. 66 That the Royal Hobart Hospital redevelopment be placed on Number of beds 0 ## 0 ## 0 hold, to ensure that a full and comprehensive service plan is developed in the context of the resources available to build and operate the service as part of a statewide health system.

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PART B

REVIEW RECOMMENDATIONS BY CLASSIFICATION: Partnerships across the entire health sector Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility Commission 2014. 46 That DHHS, as the purchaser of hospital services, develop a Partnerships across High 3 Within 12 2 6 broader range of purchasing options that includes the private the entire health months and non‐government sectors, and that THOs actively engage sector with private hospitals to explore and develop service delivery partnerships. Commission 2014. 71 That DHHS, as system manager, promote whole‐of‐system Partnerships across High 3 Immediate 3 9 collaboration to expand on, and maximise the benefits of the entire health primary care initiatives, such as Health Pathways, Care sector Coordination, and Streamlined Care Pathways programs, with the aim of adopting a more patient‐centred approach to health care across the system. Monaghan 2012. 43 There should continue to be regular meetings with Partnerships across Moderate 2 Immediate 3 6 Ambulance Tasmania, and concerted efforts by the ED staff, the entire health especially the coordinators and triage nurses, to keep the sector ambulance crews informed of progress and attempts to create capacity. Monaghan 2012. 46 While out of scope for this review, we would like to raise the Partnerships across Low 1 Within 3 1 1 question of whether there is wisdom in a free ambulance the entire health years service with 50% of the cases being referred to the waiting sector room. UTAS 4 Discuss and collaborate with Ambulance Tasmania service. Partnerships across Moderate 2 Within 12 2 4 the entire health months sector Pt First. 9 Working Better with Private and Not‐For‐Profit Hospitals Partnerships across High 3 Within 12 2 6 the entire health months sector Pt First. 11 Better Utilisation of Rural Hospital Beds Partnerships across High 3 Immediate 3 9 the entire health sector Pt First. 12 Connecting patients to bulk billing GPs Partnerships across Moderate 2 Within 12 2 4 the entire health months sector Pt First. 13 Enhanced role for paramedics Partnerships across Moderate 2 Within 12 2 4 the entire health months sector EDAP 3.1.1 The DoH should work with nearby primary care and locum Partnerships across Moderate 2 Immediate 3 6 organisations to enhance, publicise and refer patients to the entire health them as an alternative to ED attendance 24/7. sector EDAP 3.3.2 Private hospitals: The DoH/THS should use their role in Partnerships across High 3 Immediate 3 9 system oversight and management to work with private the entire health services to come to an agreed city‐wide approach to periods sector of access stress and to expand negotiated public use of private inpatient capacity as much as possible until RHH access block persistently resolves

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PART B

REVIEW RECOMMENDATIONS BY CLASSIFICATION: Consumer / Patient involvement Compiled Impact Specific finding / recommendation Classification Timeline Priority recommendations possibility Commission 2014. 10 Like clinical engagement, the engagement of consumers is Consumer / patient Moderate 2 Within 3 1 2 vital to the effective management of the health system. The involvement years benefits of community understanding of, and input into, health system decision‐making have not yet been realised in Tasmania. Commission 2014. 59 That a comprehensive statewide community engagement and Consumer / patient Moderate 2 Within 3 1 2 capacity building strategy be developed and implemented as involvement years a matter of priority. This strategy should seek to increase health literacy, health system awareness and advocacy skills. We recommend that funding to support this initiative be sourced from Element D of the Tasmanian Health Assistance Package. UTAS 5 Review the current state of ‘voice of the patient’ Consumer / patient Moderate 2 Within 3 1 2 involvement years

EDAP 1.8.1 Each major clinical service at RHH should host a biennial Consumer / patient Moderate 2 Within 12 2 4 consumer forum chaired by trained facilitators, (ideally involvement months consumer leads), and attended by unit medical and nursing heads aimed at adapting care processes to meet consumer concerns. EDAP 1.8.2 Consider including consumer representatives in Root Cause Consumer / patient Moderate 2 Within 12 2 4 Analyses and formulation of recommendations regarding involvement months major clinical events and resourcing the required consumer training. EDAP 1.8.3 Consider including appropriately skilled consumers on Consumer / patient Moderate 2 Within 12 2 4 interview panels for medical and substantial non‐medical involvement months leadership positions at RHH. EDAP 1.8.4 Include consumers wherever possible in organisational Consumer / patient Moderate 2 Within 12 2 4 improvement design initiatives and resource the required involvement months consumer training. EDAP 1.8.5 Empower patients to call out unexpected delays. Establish the Consumer / patient Moderate 2 Within 12 2 4 practice of informing patients of what will happen next before involvement months leaving the bedside; what they are waiting for, and how long the wait is expected to be so that if it doesn’t happen they can call it out. Ensure each patient knows the name of the clinician in charge of their care

Appendix 2 - Part B | 53 / 53 108 Appendix 3. Terms of Reference Department of Health

External Consultation for Emergency Department Advisory Panel – incident 10-11 April 2019 Terms of Reference

Background

Safety Event #83408 was entered into the Safety Reporting and Learning System on 12 April 2019 recording events that occurred between the 11-12 April 2019 indicating that a protracted stay in the Royal Hobart Hospital (RHH) Emergency department waiting area may have contributed to his death. The Secretary for Health wrote to the RHH Executive Director of Operations on 15 April 2019 stating that he was distressed to hear of the death and was establishing a Statutory Advisory Panel (the Panel) under section 13 of the Tasmanian Health Service Act 2018 (the Act) to be chaired by Dr Jodi Glading, Deputy Chief Medical Officer.

The Panel was to also review or direct an external consultant on its behalf to review the Patients First Initiative, identify impediments to implementation and consider recommendation arising as to whether a more comprehensive implementation could reduce the likelihood of events. The Panel has determined that the engagement of external consultants to undertake the review of the Patients First Initiative would allow for a more timely and transparent review. The Royal Hobart Hospital (RHH) is Australia’s second oldest hospital. It has a proud tradition of providing excellent service to the Hobart community since 1804 (1820 on the current site). In recent years however, in the context of increased demand, complexity and community expectations the RHH, now part of a larger emergency and acute health care sector has experienced difficulty with emergency department access to the extent that the safety and quality of care is now frequently compromised. Despite several iterations of improvement projects and governance changes across Hobart’s acute care sector, hospital access remains a formidable challenge. In addition to serious safety concerns, RHH’s difficulties with access are a source of considerable frustration and work stress for hospital staff and management, ambulance staff and their management as well as for the Tasmanian Department of Health (DoH) and the Minister for Health. Indeed, the Minister was recently subjected to a 12h vote of no confidence in the Tasmanian parliament, in part because of these concerns. Purpose

The external consultant on the Panel’s behalf will focus the review on the extent of the implementation of the Patients First Initiative, identify impediments to implementation, and consider recommendations arising as to whether a more comprehensive implementation could reduce the likelihood of events such as those on 11-12 April 2019. This review will be sent directly to the Secretary of Health. The review should learn from the findings and failings of earlier reviews in order to recommend changes that will produce timely, meaningful outcomes for consumers and staff of RHH and that will outline a path toward sustainable and ongoing improvement. Previous reviews of Tasmanian health service delivery and the RHH have often focussed on the challenges of service delineation and of sustaining adequate medical specialty representation to meet the needs of a widely and sparsely distributed

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109 community. A variety of remedies including altered governance models have been tried ranging from local to regional health boards to direct reporting to the DoH. In this climate of frequent governance change coincident with substantial infrastructure developments, it is understood that interim senior management positions are again in place, potentially exacerbating dissonant relationships between clinicians and management across the hospitals, particularly at the RHH. The access issues at RHH are significant in their own right but they may also be a symptom of this disenchantment and disengagement of the senior medical staff. In addition to sighting previous written reviews, the reviewers will need to consult directly with past reviewers as well as the Chief Medical Officer / Executive Director of Medical Services, Chair of the Medical Staff Group and the Australian Medical Association. Role and Function

The aim of this review is to recommend steps most likely to improve the safety, timeliness and quality of care at RHH by effectively reducing acute patient waiting times and improving patient throughput, thus reducing access block as per the Actions from Patients First. This will be achieved by:

1) Providing advice to the Secretary to inform the issuing of Directions as appropriate

2) Examining and, where appropriate, recommending changes to existing models of care, with particular focus on: a) In ED, i) Effective communication and interdisciplinary leadership within the ED ii) Effective communication between ED and inpatient wards. This should include agreed guidelines for a “Decision to Admit” process for admitting appropriate patients to the ward under interim orders, at the discretion of a Senior Clinical Decision Maker in the ED iii) Early patient review in the ED by an appropriate Senior Clinical Decision Maker iv) Matching staff rosters to demand distributions v) Effective use of Emergency Medical Unit beds vi) Maximising the four-hour throughput of non-admitted patients vii) Impact of the Clinical Initiative Nurses and how often they are diverted from their role in the waiting room to assist in other areas viii) Early allied health and mental health clinician involvement where appropriate to facilitate diversion to other care at the point of medical decision-to-admit ix) Options for collaborative relationships with private EDs in Hobart x) Reviewing the ED ‘red flags’ list of unacceptable events to ensure the correct issues are being regularly reviewed and acted upon

b) On the wards i) Effective communication and interdisciplinary leadership in the wards and within and between units ii) Effective communication between inpatient wards and ED iii) Effective communication between ED and subacute care iv) Effective discharge planning, starting at the point of admission, with patient/family engagement and safe transfer of care to the community with clearly delineated pathways for communication after discharge v) Effective support and planning for very long-stay patients vi) Inpatient staffing to match peak patient workloads including safe hospital at night vii) Implementation of a comprehensive “Estimated Date of Discharge” process to enable real- time and retrospective identification and analysis of prolonged stays viii) Timely discharge summaries with complete sets of discharge information ix) Implementation of a criterion-led model of discharge to enable the timely discharge of patients when it is safe to do so

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110 x) Usefulness and use of overcapacity processes to more evenly distribute clinical risk throughout the hospital

c) In Theatre i) Processes for decision making, communication and transfer of patients for procedures or surgery between theatre and the rest of the hospital (wards and ED) ii) Cancellation of theatre sessions/elective surgery, particularly as part of a criterion-based escalation process iii) Processes for identifying and moving patients who have elected to be a private patient into a private hospital for surgery and aftercare iv) Mechanisms to maintain availability of surgical staff to provide timely review of acute patients (including in the ED), regardless of operative load

d) In the clinics i) Ensure clinics provide an acute service to aid in minimising admissions/readmissions so that patients where possible are sent to clinics rather than the ED ii) Timing of and efficiency of clinics to minimise diversion of medical staff from ward activities and responses to ED requests

e) Other i) Examine the utilisation of and support provided to facilitate flow by services including but not limited to: Hospital in the Home, Aged Care outreach services to Residential Aged Care, Transitional Care, and other community support services ii) Integration of and availability of the Patient Flow Unit iii) Effectiveness of formal bed management meetings iv) Examine strategies for the hospital’s winter illness demand v) Examine what ED, ward base clinicians and the DoH has done to promote Tasmanians connecting with bulk billed General Practitioners

3) Examining, and where appropriate, recommending changes to governance particularly considering: a) Structures and processes that build trust and support between management and clinical staff b) Change management processes and the culture of improvement at RHH c) Examine hospital, service and unit structures and staffing to support the future model of care including opportunities for effective interdisciplinary communication d) Executive and unit leadership and engagement with a daily and weekly operating system to manage flow issues e) Consider training and professional development of staff to foster excellence in leadership and a culture of improvement (including, if possible, appointment of full time staff to key leadership roles), f) Non-clinical time support and utilisation, particularly for leadership roles

4) Examining opportunities for collaborative initiatives with services external to the RHH to improve acute hospital access: a) The role of, and challenges for Ambulance Tasmania and its associated initiatives (e.g. Extended Care Paramedic model, Ambulance Secondary Triage) in assisting acute access to care. b) Review the utilisation and barriers to utilisation of rural hospital beds

Outside of the scope of this review are Women’s and Children’s Services.

External consultants should be given access to data which should include but is not restricted to: 1. Hospital performance data over the last 5 years that indicates ED KPI performance, access and flow, length of stay, readmission rate, staff wellbeing and patient experience 2. Access to Health Round Table or other benchmarking data if available

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111 3. Staff turnover, retention and sick leave, including unfilled EFT 4. Sentinel events/Major incident reviews 5. Staff experience surveys 6. Previous reviews of the hospital and health service in the last 10 years including outcomes of recommendations made 7. Summary data regarding JMO rostered and un-rostered overtime 8. Ambulance Tasmania data regarding access, turnover times, staff satisfaction and engagement Membership

The external consultants to be appointed:

1) Dr Harvey Newnham, Professor and Director of General Medicine, Clinical Program Director of Emergency and Acute Medicine, the Alfred Hospital

2) Associate Professor David Hillis, Oban Consulting Member Roles

Source documents, policies, protocols or guidelines as necessary to understand the context of the events including:

o Emergency Department

1. ED presentations 3 year trends by month 2. % ED patient <=4h 3 year trends by month 3. % ED non admit <=4h 3 year trends by month 4. % ED admitted patients <=4h 3 year trends by month 5. % ED admitted patients <=4h excluding emergency short stay 3 year trends by month 6. % ED patients admitted to emergency short stay <=4h 3 year trends by month 7. % ED patients admitted 3 year trends by month 8. % ED patients admitted excluding emergency short stay trends 9. % ED patients did not wait trends 10. % Urgent ED unplanned representation (triage cat 1 and 2) <24h post ED discharge 11. % ED patients seen within time 12. Multiday discharges unplanned and planned readmitted via ED <30 days 13. Number of ED admissions discharged <24h 14. Number of ED admissions discharged <24h excluding emergency short stay 15. Average Multiday LOS (non-elective patients) 16. % of Emergency stay patients admitted to an inpatient ward other than ED short stay 17. Road ambulance time to first treatment 18. % Ambulance handover <40 mins 19. Number of ambulance arrivals 20. Time to first treatment (Mins) 21. ED LOS Admitted patients (hours) (Mean, Median, Mode) 22. ED LOS admitted patients excluding Emergency Short stay (hours) (Mean, Median, Mode) 23. ED LOS non-admitted patients (hours) (Mean, Median, Mode) 24. ED short stay LOS (hours), emergency type patients 25. ED LOS >24h numbers

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112 o Elective surgery

1. % Cat 1 admit within time 2. % Cat 2 admit within time 3. % Cat 3 admit within time 4. Number of hospital initiated postponements per 100 scheduled admissions 5. % ready for care

o Occupancy

1. Ave Daily multiday beds occupied (including Emergency short stay and AMU) 2. Average daily discharges - weekdays 3. Average daily discharges - weekend days 4. Total multiday discharges 5. Number of Long Stay patients currently admitted >=7 days 6. Number of Long Stay patients currently admitted >=15 days 7. Number of Very Long Stay patients currently admitted >=31 days 8. Average Hospital in the Home Occupancy 9. Average Hospital in the Home Occupancy or referral by parent unit 10. Average Hospital in the Home Length of stay 11. Average multiday length of stay non-elective type patients 12. Average multiday length of stay elective type patients 13. Average multiday LOS (non-elective type patients) for each major unit 14. Average multiday LOS (Elective type patients) for each major unit 15. ICU ANZICS or other registry data 16. ICU admissions, number 17. ICU LOS 18. Average number of ICU beds not opened due to no nursing staff available each week

o Hospital Transfers

1. Acute transfers in from other health services (public and private) 2. Acute transfers out to other health services (public and private) 3. Subacute transfers out 4. Transfers in from subacute

o Clinics

1. Urgent appointments within target 2. Routine appointments within target

o Mental and Addiction Health

1. Average multiday Length of Stay (Emergency Type Patients) 2. Average multiday Length of Stay (Elective Type Patients) 3. Number of Emergency Admissions through ED 4. Number of direct admissions 5. % ED Patients admitted <=24h 6. 28 day unplanned readmission rate 7. % post discharge follow up adult/youth completed within timeframe 8. Seclusion rate/1,000 bed days adult/youth 9. Restraint rate/1,000 bed days 10. Number of outbound interunit transfers 11. Number of inbound interunit transfers

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113 o Other data

1. Hospital Acquired Complication rates by type and by division 2. Surgical mortality reports 3. Standardised hospital mortality ratio 4. SAC 1 events last 3y 1. SAC 1 events with RCA report within 70 days 5. Hospital acquired Staph Aureus Bacteraemia rate per 10,000 bed days 6. ICU Central Line Associated Bloodstream Infections (CLABSI) 7. Surgical site infection (number of patients) 8. Hand Hygiene compliance 9. Recommendations from college reviews for training purposes of major hospital units/services 10. NWAU performance according to targets 11. % of separations that are compensable patients 12. Residential Aged Care KPIs if applicable

o Workforce

1. Lost time for workcover 2. Lost time injury due to occupational violence 3. Staff experience surveys 4. Average sick leave by month for last three years

o Consumers

1. Patient experience surveys 2. Consumer involvement in hospital process design

Meeting Times

The external consultants should visit the RHH to conduct the review interviews and data review between May 20th and June 5th.

Pending further discussions, the external consultants will provide a draft report by Wednesday 12th June 2019 and the completed report by Monday 1st July 2019. Meeting Protocols

 Any interest held by members must be declared, and any conflicts arising must be managed.

 The reviewers will meet with key Dept of Health staff, Hospital executives with responsibility for clinical services, patient flow and staff wellbeing, Program/service leadership, heads of major inpatient units, key subacute leads, HITH lead and a variety of ward based and ED staff. The list should include but is not restricted to:

o Chief Medical Officer, DoH o Deputy Chief Medical Officer, DoH and Chair of Advisory Panel

o Chief Operating Officer, THS o Executive Director of Operations, RHH o Director of Clinical Services, RHH

o Executive Director of Medical Services, RHH

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114 o Executive Director of Nursing, RHH o Director, Emergency Department, RHH

o Stream Leader and Director of Nursing, Clinical Support RHH o Stream Leader and Director of Nursing, Surgical and Perioperative Services, RHH o Stream Leader and Director of Nursing, Medical Services

o Clinical Lead, Mental Health Services, RHH o RHH Directors of Cardiology, Respiratory Medicine, Radiology, Pathology and Medical Imaging o Stream Leader and Director of Nursing, Subacute Care

o Clinical Lead, Allied Health o ED Specialists, registrars and nurses o Inpatient consultants, registrars and nurses

o Representative, Primary Health Care o Patient representative o Ambulance Tasmania service leads

o Ambulance Tasmania staff/crews in direct patient contact

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115