1. Management of waiting lists at national level in Croatia. Reinventing the wheel... Assist. Prof.Dragan Korolija-Marinić Consultant surgeon University Hospital for Tumours, Zagreb, Croatia University Hospital Center Sestre milosrdnice Assistant Minister of Health (2014 june-2016 feb)

2. Presentation content 1. Hospital sector status in Croatia 2. Business process improvement a) Main activities b) HTA c) Waiting lists management – Programme Plus 3. Conclusion

3. 1. Hospital sector status Hospital financial underperformance 2013 – National health care fund payed in advance 90 mil Euro 2014 – 55 mil Euro Repeated financial support to hospitals during 20 years period 2,2 bil. Euro (1994. – 2014.), 2014. – 400 mil. Euro Waiting lists Long, big and inaccurate

4. Reducing waiting list for elective care Policy strategies: 1.Increase supply – increasing activity, increasing capacity, using capacity more efficiently. 2.Reduce demands – ilness prevention, prioritising patients, eliminate inappropriate tests and treatments. 3.Local organizations strategies – incentives and sanctions for hospitals which meet targets. Kreindler SA Br Med Bull, 2010.

5. Devil’s triangle Negative financial results Not enough doctors Not enough money Hospital underperformance Big waiting lists Not enough patients

6. Angels Triangle - Thesis: Will more efficient process improve results ? Positive financial result Human resources Rational resources managment usage Optimal performance Short waiting lists Gudilenes and pathways implementation sdgbsb

7. Number of services in hospital sector (2011 – 2014) sdgbsb Outpatient service Inpatient treatment

8. Major change in 2015....D-Day National insurance fund leaving the Treasury Operating indipendently Mid-term planning Pay-for-performance contracting for hospitals

9. Programme Plus – patients in the center of care Start-up: 11 Feb 2015 – World Day of the sick Target: increase access and efficiency of services, additional working hours: Wednesday afternoon and Saturday morning. Programme evaluation – decrease in average waiting time (days) and number of patients on waiting lists...

10. Programme plus – first ten weeks First four weeks: 21.451 patients Ten weeks: 47.139 patients !! Great public support...media, NGO....

11. Number of services (patients) – Jan / March 2015 vs. 2014

12. Results – first ten weeks – national level Significant decrease in average waiting time Apr 2014 - 155 days vs. Apr 2015 - 132 days (15 %) Seasonal increase compensation (February - April) 2014 – increase for 58.678 referals (01.02 - 08.04.2014.) 2015 – increase for 16.547 referals (01.02 - 14.04.2015.) 42.131 referals less (patients waiting) compared to 2014 !!

13. First ten weeks results - national level – Significant decrease in number of patients waiting (green) – Significant decrease in average waiting time in days (green) Trends by specific procedures Programme bensfits GastroscopyColonoscopyMRICardiac ultrasound 11.02.20.04.Ratio11.02.20.04.Ratio11.02.20.04.Ratio11.02.20.04.Ratio No of patients4.4503.919-12%3.9683.9630%19.49918.402-6%16.11015.090-6% Av. waiting time (days) 8174-9%115109-6%212206-3%214204-4%

14. Positive examples from Croatian hospitals 20.04. vs 11.02. MSCT – UHC Rijeka Number of patients decreased from 605 na 453 (25%) Average waiting time (days) decreased from 66 to 58 (13%) Cataract surgery – UHC Rijeka Number of patients decreased from 876 to 530 (39%) Average waiting time (days) decreased from 154 to 118 (23%)

15. Positive examples from Croatian hospitals Cardiac ultrasound – GH Bjelovar Number of patients decreased from 836 to 333 (60%) Average waiting time (days) decreased from 320 to 241 (25%) – UHC Rijeka Number of patients decreased from 1.388 to 970 (30%) Average waiting time (days) decreased from 150 to 122 or zero! (19%)

16. Waiting lists comparison 2014 vs. 2015 1.1.2014.15.6.2014.31.12.2014. 13.4.2015.

17. Waiting lists comparison 2014 vs 2015

18. Results Feb 2015. – Ratio of hospitals with service within 60 days Nov 2015. – Ratio of gospitals with service within 60 days First consultation64%74% Clinical examination80%81% Gastroenterology35%71% Cardiology50%71% Neurology93% Ophtalmology39%43% Therapeutic procedures29%43% Cataract surgery29%43% Diagnostics60%67% Gastroscopy64%82% Colonosscopy70%76% Mamography76%96% Abdominal ultrasound56%57% Carotid color doppler81%80% Breast ultrasound38%37% Cardiac ultrasound37%52% Total – 13 services60%69%

19. Final results Activities started in Feb 2015: Programme plus, 72 HOURS, Open days week, Top ten doctors. 1,2 milion services more (total of 13,2 mil.). 21 % reduction in average waiting time (days) from February do December 2015. Minimal additional cost. 42 percent of hospitals had positive balance sheet at the end of 2015.

20. Conclusion More efficient and productive processes can decrease waiting lists and result in better hospitals performance – Increase supply !! Key points are more services and proactive localhospital management. Administration must be present in hospitals ! After 20 years this was the first year to achieve financial stability in healthcare sector as oppose to some European countries....

21. Thank you for your attention... ‘The only way is up’