GUEST BLOG: Ian Powell – When overlaying fact in health systems with fiction morphs into embellishment

In discussing what he believes to be his health system understanding and prowess Health New Zealand Commissioner Lester Levy is known on several occasions to refer to what he describes as the “turning around” North Shore Hospital’s emergency department performance.

Commissioner Levy has a context

This is in the context of two things. First, to defend his and the government’s untenable position that health spending can be cut without affecting health services.

The second is achieving the ‘six hour health target’. That is, 95% of patients are to be admitted, discharged or transferred (into the hospital) from an emergency department within six hours.

“Turning around”

Rachel Thomas reports Lester Levy’s “turning around” ‘success’

Levy’s “turning around” scenario is captured well in The Post health journalist Rachel Thomas’ paywalled article (18 January) citing Levy in his own words:

He used the example of, years ago, turning around North Shore Hospital’s emergency department performance, from 61% of people discharged within six hours, to 95% “with the exact same people”.

He says no, that isn’t code for making everyone work harder, but says the secret will be in more clinically led decision making which moves decisions and resources “close to the action”.

In essence, he is saying that under his governance as Waitemata District Health Board Chair:

• North Shore Hospital’s emergency department improved its performance thereby enabling it to achieve the government’s new six hour target;
• this was achieved without the need to increase ED staffing; and
• ED staff were not required to work harder.

This would be very impressive if not for one small detail. It is not true. In summary:

• the emergency department’s improved performance was due to actions undertaken before Dr Levy was appointed Board Chair in early 2009; and
• the six hour target was not about ED performance but instead ‘whole of hospital’ performance. Emergency departments are barometers for how well the hospitals they are located within are functioning. It was about increasing the inpatient bed capacity and capabilities of the hospital so that patients who needed to be transferred out of the ED could be within six hours.

It started with the Health & Disability Commissioner

Following receipt of complaints the Health & Disability Commissioner initiated an investigation into the performance of North Shore Hospital during the period March-October 2007. The focus was on the emergency department (then called the emergency care centre).

Health & Disability Commissioner has a statutory responsibility for protecting patient safety

Its report was damming, not of the clinical staff responsible for the affected patients, but instead of the DHB’s leadership:

Although four of the five patients died, there is no evidence that treatment injuries or lapses in care caused their death. But in significant ways Waitemata DHB‘s care for all five patients breached the Code of Health and Disability Services Consumers‘ (the Code). They suffered delays in care and deficiencies in communication with them and their families. The failings were not the fault of individual staff but the result of systemic issues, overcrowding, and pressures on staff. In such an environment, non-urgent care is often given low priority as staff focus on the bare essentials in an effort to keep patients safe. That happened at North Shore Hospital. Although the standard of medical care was largely reasonable, the nursing care was not. The nurses did not have time to care.

Although not published until April 2009, well in advance knowledge of its findings became quickly known in both North Shore Hospital and the DHB, and then in wider health system.

How the DHB responded

What really did happen at North Shore Hospital?

Management did not have the expertise to develop the response. Instead, sensibly so, it was clinically led (in this specific sense, Lester Levy’s reference to clinically leadership is correct).

Helen Clark: her government responded quickly to capital funding request

The response required additional capital funding which the Board and senior management prepared and pursued with then Prime Minister Helen Clark’s government (Clark reportedly even visited the hospital).

The form of the response was the construction of a new 50-bed short stay unit called the Assessment Diagnostic Unit (ADU).

The government promptly came to the party and the process was expeditious. Before completion the new unit also won a national design award for a public service building.

In 2011 construction was completed and the ADU opened. However, the clinically led development and planning (the ‘grunty stuff’) was completed well in advance. Although supportive, the ‘foundations’ were laid before the arrival of Lester Levy.

What was the Assessment Diagnostic Unit

The objective of the ADU was to improve overcrowding and patient flow from the emergency department and increase inpatient bed capacity within the hospital (ie, prevent bed-blocking).

Simply put patients who could neither be discharged nor admitted to a ward bed were transferred into the ADU.

However, it was not a ‘holding pen’. The clock began ticking when each patient arrived. There was a deadline of 24 hours for the patient to be either discharged or admitted into a hospital ward.

Significantly patients in the ADU were not looked after by emergency department staff. The ADU was not part of the ED and patients were diagnosed by multi-disciplinary health professional teams from within the hospital (mainly physicians and medical nurses).

The prime benefit of this clinically led innovation was improved and safer patient care. It was an impressive response to a previously out-of-control situation brought to the fore by the Health & Disability Commissioner.

Waitemata DHB got an additional benefit from its ADU

But there was also a consequential further benefit. Waitemata DHB was able to achieve the six hour target when it was introduced.

This was because the ADU patients were no longer in the emergency department. They were transferred out of the ED within six weeks even though not into a ward bed.

Further, it did not require increasing emergency department staffing because it was not necessary. However, it was necessary to increase staffing within the hospital itself in order to service the ADU.

This was not ‘gaming’ the system to achieve the target. It was a clinically led response to adverse patient tragedies that was implemented in a timely manner.

As discussed above, the target was not an ED target; it was a ‘whole-of hospital’ target caused by bed-blocking in hospital wards.

Subsequently other public hospitals with emergency departments implemented similar innovations often called Medical Assessment and Planning Units (MAPUs).

Irrelevance of embellished claim today

However, while innovative and improving patient care, emergency department and these assessment units are now being overwhelmed by uncontrolled rising acute demand (patients whose care can’t be deferred) and increased complexity of patients’ conditions.

Rising acute demand and rising health complexity are largely due to the increasing impact of external social determinants of health, such as low incomes and poor housing. These are largely outside the health system’s control.

However, they are compounded by severe widespread health professional workforce shortages both in community and hospital care. This is the result of longstanding political and health system leadership neglect.

Commissioner Levy has been accused of being party to “manufacturing” a financial crisis; now he is “manufacturing” a solution

This means that the successful innovation at North Shore Hospital, which had the additional benefit of achieving the six hour target, not only wasn’t attributable to implicitly or otherwise to Lester Levy.

This additional benefit, contrary to his assertion, is now unable to be achieved while under-funding and under-staffing continue.

The state of the health system in the mid-2020s is far worse than it was in the early 2010s. One only needs to read the paywalled feature article on the current dire state of emergency departments and hospital bed-blocking by Michael Morrah and Chris Knox today (17 February) for confirmation.

 

 

 

 

Ian Powell was Executive Director of the Association of Salaried Medical Specialists, the professional union representing senior doctors and dentists in New Zealand, for over 30 years, until December 2019. He is now a health systems, labour market, and political commentator living in the small river estuary community of Otaihanga (the place by the tide). First published at Otaihanga Second Opinion