The challenges of establishing a hospital group

Establishing a group hospital is a marathon, not a sprint, as sustainable change must be built on good solid foundations, Ann Doherty, CEO of the Mid Western Regional Hospitals Group, one of the prototypes for the new hospital groups, tells Maureen Browne.

Establishing a group hospital is a marathon, not a sprint, as sustainable change must be built on good solid foundations, according to Ann Doherty, CEO of the Mid Western Regional Hospitals Group, one of the prototypes for the new hospital groups.

Ann Doherty
Ann Doherty

The group, soon to be re-branded as University of Limerick Hospitals Group, consists of six hospitals – one Model 4 hospital, Mid Western Regional Hospital in Dooradoyle, Limerick,  the dedicated Cancer Centre, primary PCI centre and 24/7 emergency centre, and  3 Model 2 hospitals, Nenagh Hospital, Co. Tipperary,  Ennis Hospital, Co. Clare and St John’s Hospital, Limerick. There are two single specialty hospitals, the Mid Western Regional Maternity Hospital in Limerick (a stand alone Maternity Hospital, which they would like to have on the Dooradoyle site) and the Mid Western Regional Orthopaedic Hospital in Croom, Co. Limerick.

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Ann Doherty, a former HSE National Director of Acute Hospitals, was appointed CEO of the Group in January 2012. “The Mid West was a bit different to other areas, as much of the re-configuration had already been done.  Group thinking was in place, there was no acute surgery in the smaller hospitals in the group and a lot of services had been centralised on the Limerick campus. What was not there and what we are still working on is the culture change to ensure that each of our hospitals feels part of the whole. The big thing is to drive the notion of a single hospital system and that doesn’t happen overnight”.

People will retain their loyalty to the past and the extent of this will probably depend on whether it is seen as a hostile merger or a harmonious coming together.

“The challenges of establishing groups will not be the same all over the country. The makeup of our Group with Model 4, Model 2 and single specialty hospitals would be very different to, for example, the Dublin situation. However, I think the cultural change will be common to all. You can do lots of things around performance and indicators, but the cultural change takes a bit longer.  People will retain their loyalty to the past and the extent of this will probably depend on whether it is seen as a hostile merger or a harmonious coming together. It hasn’t been a hostile takeover in the Mid West, it’s been much more amicable, but there are still individuals in the smaller hospitals, and some in the  larger hospital too, who feel this is not the right thing to do. We need to listen to these people and not write them off because we need to understand what they are saying and ensure that we are satisfied that we have put measures in place to address all the issues raised.”

The Mid Western Regional Hospital Group is beginning to become a single hospital system, with one CEO and an administrative Board, chaired by Prof. Niall O’Higgins. The primary task for the Board is to prepare the organisation to become a Trust.  Until the law is changed to give the Board executive status, Ann Doherty will also report to the HSE National Director of Hospitals. An executive team for the Group has just been developed.

The Group has four Clinical Directorates working across the hospitals in an integrated way,  which are responsible for the delivery of services in what is effectively a virtual hospital stretching across three counties. Each Clinical Directorate includes the Clinical Director, a directorate operational manager, a directorate nurse manager, and is supported by individuals with expertise in Clinical Governance, Finance and HR. On the Ennis and Nenagh sites traditional hospital management has been replaced by the appointment of Operational Directors of Nursing, who are responsible for the day to day services. St. John’s voluntary hospital is also part of the group, but it is a separate entity with its own CEO and Board of Governors. “The relationship is managed formally through a Section 38 service arrangement but on a day to day basis there is a close working relationship in place. In the long term it would be highly desirable to have closer links.”

It has been a very interesting journey, working within the HSE trying to develop an organisation, the raison d’être of which is to disassociate itself from the HSE.

Ann Doherty said that, in her opinion, turnaround does not happen very quickly, or if it does, one must question its sustainability. “It has been a very interesting journey, working within the HSE trying to develop an organisation, the raison d’être of which is to disassociate itself from the HSE. I believed that the first challenge was to get people into a space of self belief and while we are not 100 per cent there yet, I believe we can get there. There are great opportunities in a group – I don’t think we could have achieved the targets we did achieve last year if we didn’t have the flexibility of a group.

“Our group is not about one hospital being good and another not as good but it is an opportunity for each to be excellent at what they do.  Smaller hospitals have really important roles as Model 2 hospitals and have been exemplary in their performance, with services expanding rather than contracting. Both Ennis and Nenagh Hospitals now have state of the art endoscopy units and day surgical services. Each has an individual and complementary role but not a competitive one.

She agrees that the staff moratorium has been a challenge, but says there will always be rules, no matter which system we work in. “Autonomy has to be earned and there are benefits for our being part of a larger system at the moment. There is a preparatory piece of work to be done to enable us to move towards independence and this has to be done purposely and carefully.

“We got some additional funding this year for which we are very grateful, but unfortunately we still have an enormous financial challenge. The Mid Western Regional Hospitals Group has an unusual history. The hospitals collectively broke even up to the latter part of 2009, and then changes were put in place with the expectations that resources would follow them, but these resources were not realised.

“We need a multi annual approach to recovery. If you are trying to bring people with you, you need to give them the opportunities to be successful. The development of the Clinical Leadership model associated with the roll out of Clinical Directorates is the future and they must be given the chance of success.

The relationship with UL is very important to the hospitals and to the university also. The President of the University of Limerick is a member of the Mid Western Regional Hospitals Group Board and they are planning to appoint a Chief Academic Officer to the management team in the coming months. Six professors have been appointed in the last two years in partnership with UL and the Board has decided to rebrand the group as UL Hospitals, with the Regional Hospital being known as University Hospital, Limerick, the maternity hospital as University Maternity Hospital,  and the other three hospitals reverting to their former names of Ennis, Nenagh  and St John’s Hospitals.

Ann Doherty says that they are very fortunate in the mid west, as an integrated service area and they work very closely with colleagues in the community.  “I think we should have a service arrangement with the community primarily based on performance expectations for both services of each other. For example I should be assuring the community that patients will not be waiting on trolleys and they should be assuring me that there will be no delayed discharges.”

There is a preparatory piece of work to be done to enable us to move towards independence and this has to be done purposely and carefully.

The Dooradoyle campus is a very busy site at the moment with an enormous capital development programme… A new Critical Care Block has just been finished, cardiac services have moved and are now delivering a 24/7 primary PCI service. The Intensive Care and High Dependency Units are currently being equipped with a view to opening over the summer months. New facilities for Parkinson’s, stroke, breast cancer and dermatology services are currently being built as part of a new six story building on site, supported by a number of charities who have come together to provide the capital monies. Construction for a new Emergency Department has commenced and a clinical education building in partnership with UL is at tender phase. We are at planning permission stage for a new dialysis unit (another development supported by the Mid Western Hospitals Development Trust) and we are in the design phase for a new ward block to replace the existing inpatient accommodation.

On the Ennis site a new 50 bedded single ensuite room unit has just been formally opened by the Minister, whilst on the Nenagh site the development of new theatres is well underway.

“I feel very privileged to have had the opportunity to be part of something new and developmental. It is not easy for staff working in the current system restraints but I do believe that there are great opportunities ahead for our group”