Governance and accountability challenges

Beaumont Hospital CEO Liam Duffy warns of governance and accountability challenges in implementation of HSE National Strategies and development of Academic Health Centres.

Beaumont Hospital Dublin CEO, Liam Duffy has warned that while there is much good in the new HSE National Strategies their implementation poses governance and accountability challenges while a range of dilemmas and challenges also surround the development of the new Academic Health Centres.

Liam Duffy
Liam Duffy

Speaking on “Hospital Governance in a Transitioning Healthcare Environment” he explained how Beaumont had  implemented an organisational development programme over the last four years to ensure that it remained “ a leading edge healthcare provider” and to create an organisation that is fit for purpose, which is the  delivery of safe high-quality services.

Liam Duffy said that under voluntary hospital governance, the CEO was accountable to the hospital board for the running of the hospital, for its day to day operations, meeting targets, working within budget, ensuring patient safety, developing expanding services and corporate and clinical governance. Funding was decided by the Department of Finance but the Department had no accountability for the implications for or the impact on services.

The CEO and hospital management accountability were currently undefined.

Under the HSE management structure, the CEO reported through the Network Manager, Regional Manager and various Corporate HSE functions on delivering the service plan, meeting Healthstat targets, liaising with the community and co-operating with wider health systems initiatives.  Sanctions and incentives were involved.   Failure to meet targets could result in financial penalties and restricted development funding, hospitals which agreed on A & E waiting times could get minor capital grant while hospitals  which went “red” on A & E wait times faced sanctions  up to considerations of closing down the department.

Licensing implications

Under the HIQA Governance, the Hospital Board and the CEO were accountable for “Patient Safety Framework” compliance with all the standards etc and failure to meet these requirements had licensing implications.

Dealing with governance and accountability under the National Strategies, Liam Duffy said the CEO was responsible for implementing the strategies and programmes and failure to implement them resulted in threats of withdrawal of programmes, and removal of Centres of Excellence status.  However, the governance was very unclear for hospital management and for staff assigned to the programmes.   For example was the hospital CEO responsible for staff assigned to the programme but not working for the hospital.

The National Clinical Director worked through the hospital‘s Lead Clinical Director and other Clinical Directors and Consultants.  The CEO and hospital management accountability were currently undefined.  They could be left wondering what was happening at Clinical Director meetings and what they would have to do to implement decisions taken at these meetings.

The hospital was reconfigured – moving from traditional centralised structures to devolved management

However, he said that as a result of the introduction of the Clinical Directors, he could see a huge change in terms of getting decisions taken by clinicians.  Decisions which previously could have taken three to twelve months to reach were now taken speedily.

Turning to Academic Health Centres he said that Beaumont Hospital, Connolly Hospital and the RCSI were working closely together.  It was important to establish how existing structures would fit in with the new structures, how management structures would end up across a number of sites, how academic and service provider institutions would be combined and the governance implications that went with this.

Dilemmas and challenges

“In overall terms AHCs are some way off.   However, if the plan is to commence with merging/combining management structures across hospital sites it will be important to have some vision on how the overall entity might operate.

“Dilemmas and challenges for hospital management include the minefield of structures and competing priorities. This is compounded by the transitory state of structures.  We  have to consider if the internal structures that we and other hospitals have created interface with the emerging external structures, how hospital services will be integrated with PCCC, what regionalisation will look like and how one hospital on three or four sites will fit in with HSE plans and non for profit sector.

“Will the ‘new  models’ embrace all healthcare providers (private, public voluntary etc) in a region; will the current AHC models fit with the eventual regionalised models;   how will CEOs/Hospital Managers influence future decisions;   how can we ensure that what is being designed results in real improvements in services to all patients and not just those in high risk categories.”

“We must also wonder if the current strategy would change if there was a change in healthcare funding and it moved to the insurance based model.”

In 2006 the Hospital adopted a high level action plan incorporating strategic and operational developments.

This took into account the hospital’s internal priorities and targets including clinical and capital developments, KPIs, balanced scorecard, financial targets, patient safety and quality, internal process improvements and efficiencies and employee development and growth.

It also took into account the external environment which included regionalisation, lead Clinical Directors, National Strategy of NPRO, HIQA Strategies & Governance, Academic Health Alliances, the Departments of Health and Finance and An Bord Snip.

Activities under the plan were grouped under five key themes representing a “whole systems” approach to strategic change and development.

  • Operational Excellence – to ensure effective and efficient delivery of services and what processes systems and quality improvements needed to be undertakenOrganisational Design – to identify the structures/organisation design best supporting the delivery of quality/safe services
  • Learning and Development – To ensure Beaumont remained a leading edge healthcare provider contributing to medical and clinical research and delivering innovative services and to identify how the hospital could continually develop and support staff.
  • Corporate identity and communication – To ensure the hospital created a strong identity and image which inspired confidence and allowed it to influence and contribute to national healthcare policy
  • Culture change – As “culture eats strategy, tools and techniques for breakfast” to ensure that a focus remains on the “cultural shifts” necessary for a flexible adaptable patient focused service.  As part of the culture change they opened services on an 8 a.m – 8 p.m. basis rather than as previously on a 9 a.m. – 4 p.m.

Devolved management

The hospital was reconfigured – moving from traditional centralised structures to devolved management. This was influences by the HSE, the Department of Health & Children, HIQA, Centres of Excellence, National Strategies, Patients and Families, the General Public, the cancer strategy and care of older people.

Services were grouped under  three headings – Corporate (covering OD, HR, Finance, IT, IQS, Medicine Administration, Service Planning, Executive and Leadership;  Therapies covering Allied Health Professionals, Pharmacy, Medical Physics and Clinical Engineering and Facilities covering Patient Services, Catering, Portering, Security, TSD and Hygiene.

Seven Directorates had been established which were configured closely around existing Cogwheels and Nursing Divisions.   They are  (1) Medicine, (2)  Neurosciences, Cochlear Implant and ENT, (3) Nephrology, Urology and Transplantation, (4) Critical Care and Anaesthetics; (5) Surgery, (6) Radiology and (7) Laboratory medicine.

Among  the most significant approaches were the creation of the hospital OD Department in 2007,  the negotiation of the new consultants contract, research of best practices  nationally and internationally and management direct engagement with specialty teams over a three year period prior to and during the design phase.

“CEOs get involved in crises – but the OD department and keeps us focused on what we should do and what is being done.  It is the conscience on our shoulder.

“I believe it is vital that we invest in our people. We must make learning development programmes available to give people who wish to move on the opportunity to do so.    Some people may wish to continue doing the same job for 20 years and that’s fine but for others it is important that they are enabled and facilitated to change.”

To see Liam Duffy’s presentation click on http://www.hmi.ie/Events.htm#Clinicalforum