1. Hospitals and healthcare management – what are the overall challenges Liam Woods Director of Acute Services (Interim), HSE 3rd March 2016

2. Content 1.Risks 2.Demographics 3.ED 4.Access 5.Capital investment 6.Solutions!

3. System of Internal Control Risk that a lack of a system of adequate internal controls will cast doubt over the accuracy of the Financial Statements and compliance with laws, regulation and policy. It will further reduce the ability of the HSE to realise the aims of the current service plan, and will not foster a culture of value for money and continous improvements. Final Access to services On a timely basis

4. Risk HCAIs ICT Acccess to service

5. Demographics

6. 6 Ireland’s population is increasing and ageing. This will impact Hospital bed but by how much NCPS use CSO data for reports February 2016 - Confidential Will increasing population age impact on capacity?

7. 7 Age profile change pushes AvLOS up Population increase pushes # inpat. up NCPS combine population trends with HIPE data for reports February 2016 - Confidential Will increasing population age impact on capacity?

8. OECD length of stays Health in Ireland Key Trends 201420082014% Acute Beds1184710480-11.54% In Pt discharges5921336227635.17% alos6.035.43-9.95% day cases77061795725824.22% Emergency Attendances115067412175725.81% Note additional 1000 bed Capacity created through los reduction whilst reduction of 1367 in absolute capacity

9. AreaWhite (all ethnicity) excluding Irish Travellers % Irish Travellers % Black % Asians %All others & Not Stated % Donegal96.70.50.60.81.5 Galway City88.12.033.72.83.1 Galway Co.95.61.40.60.71.7 Leitrim95.80.80.30.92.25 Mayo95.81.10.51.01.7 Roscommon95.50.60.71.02.1 Sligo94.90.6 1.32.5 State93.60.71.41.92.5 Diversity Galway City has the most ethnically diverse population nationally: 22% Also has highest proportion of Travellers followed by Co Galway, Longford, Offaly, Mayo. 40% increase in Travellers in Galway City since 2006 Irish Traveller Population Much younger than general population: 3/4 aged 34 or younger Less than 1 in 10 are over 54. 41 % more children aged 0-4 than in 2006

10. Endoscopy Activity v Waiting Lists 2014 - 2015

11. ED

13. SDU 2016 Crossroads 1.Status Quo 2.More Demand 3.Have Change Prescribed 4.Low Morale/Frustration 5.Feeling that no- one understands how hard we work to fit everything in 6.Not enough capacity. 7.Fed up –sick of external people telling me what’s right 8.I have the job but is my authority respected? 9.How do I resolve conflict?

16. 30 DMA 2016 v 2015

17. Trolley data

18. Trolley Totals - 2015/16 Comparison 1-Jan to 19- Feb 2015/2016

19. Attendances/TrolleyGar Analysis Attendances 9.6% o OLOL 12.2% o Cavan 11% o Connolly 12.4% TrolleyGar 2.2% o OLOL 40.3 % o Wexford 32.8% o St. James’s 30.1 %

20. Attendances/TrolleyGar Analysis Attendances 9.6% o Waterford 10.5% o Mayo 19.7% o Sligo 12.1 % TrolleyGar 2.2% o Letterkenny 82 % o Mayo 41% o Portiuncula 84.3 %

21. Influenza activity for week ending 14/2 Rate was 73.4 per 100,000 population in week 6 2016, a slight decrease compared to the updated rate of 79.5 per 100,000 reported during week 5 2016

22. Additional Capacity (New & Closed)

23. Delayed Discharges

24. What type of system?

25. PJH/AK/SDU FEB 2015 Clinical risk facing patients delayed for admission Patients run a 43 per cent increased risk of death after 10 days if they are admitted through a crowded accident and emergency (A&E) department (Richardson DB, 2006). Hospital mortality and hospital LOS are associated with length of ED boarding. Singer et al (2011) Waiting for admission in A&E is also associated with significantly longer hospital length of stay –on average 2.35 days longer where a patient stays in A&E for more than 12 hours. (Liew, D. Kennedy M, 2003). Patients admitted at the weekend have longer lengths of stay and higher morbidity and mortality (Bell et al 2001, Bell 2013)

26. Navigation Hub/Visual Hospital PJH/AK/SDU FEB 2015

27. Measurement can lead to improvement only in organizations that have a culture of accountability and a workforce skilled in quality-improvement science. PJH/AK/SDU FEB 2015 Culture shapes behaviour much more effectively, consistently and profoundly than targets, West (2014)

28. Access

29. Orthopaedic Surgery Model of care on HSE website

30. Key Focus Areas Waiting Lists Workload Analysis Inpatient & Day Case Discharge trends Workforce planning Other orthopaedic resource requirements Planning for the future

31. Waiting Lists as at 28 January 2016 Inpatient/Day Case Waiting List – 9,815 (786 waiting 12 months or longer) Outpatient Waiting List – 44,968 (5,060 waiting 12 months or longer)

32. Workload Analysis 86% of orthopaedic inpatients have a surgical primary procedure during their stay in hospital 69% of this inpatient activity is lower limb Day case patients (37%) are less likely to have an operation Upper and lower limb day case surgical volumes account for 78% of surgical day case procedures

33. Inpatient & Day Case Discharge Trends

34. Workforce Planning Population of 4,588,252 (Census) Currently 84 Orthopaedic Surgeons Current ratio 1 per 54,000 of the population Recommendation - 7 major orthopaedic groups with 27 surgeons in each group (National Model of Care Trauma & Orthopaedic Surgery 2015) Resulting ratio based on recommendation - 1 per 24,000 of the population

35. Nursing 1998 – Commission on Nursing – expansion of nursing and midwifery roles Role of Clinical Nurse Specialist and Advanced Nurse Practitioner No single nursing staff to patient ratio that can be applied across the whole range of wards to safely meet patients’ nursing needs NICE guideline (NICE 2014) recommendations on factors that ensure that patients receive the care they need, including specialist nursing Role of fracture liaison nurse - no. of fragility fracture five times the number of hip fractures

36. Other Orthopaedic Resource Requirements Dedicated access to theatres Appropriate access to diagnostics Access to diagnostic radiology (CT and MRI) and interventional radiology

37. Planning for the future Implementation of robust workforce planning – correct consultant to patient ratios for consultant delivered service Implementation of innovative strategies across the spectrum of care from primary care through to acute care and rehabilitation Develop nationally standardised guidelines for referral from GPs Expand the acute and community musculoskeletal physiotherapy services Continued development of outcome measures similar to the Irish Hip Fracture Database

38. Capital Equipment

39. Radiology and Critical Medical Equipment National Replacement Costs €M over 5yrs

40. Solutions

42. Productivity / ABF view, funding Additional Funding Clinical leadership and change Output of clinical programmes Demographic planning

44. 44 NCP / HIU / HIPE / OpenApp -> NQAIS Surgery Discharges between 2010 and 2014 (including Acute and Elective admissions for surgery or surgical care) National figures Acute & Elective discharges from Model 4, 3 & 2 hospitals excluding Maternity, hospice and rehabilitation type hospitals February 2016 - Confidential HIPE DATA