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Gauging the manager’s perspective

The last 25 years have seen a great deal of change in the Irish healthcare system — not least in the Southern region, where immense transformation has occurred in recent decades. 

Since 1992, Mr Tony McNamara has served as Chief Executive Officer (CEO) of the Cork University Hospital Group, managing a combined budget of €410 million and a whole-time staff equivalent of around 4,500.

The group includes Cork University Hospital (CUH), Cork University Maternity Hospital (CUMH), Bantry General Hospital (BGH) and Mallow General Hospital (MGH).

“We have seen significant investment of over €400 million in capital developments at the hospital here, particularly over the last 12 years,” Mr McNamara told the Medical Independent (MI).

“In the initial years, there was little capital investment but that changed significantly with the first national development plan that came out in the late 1990s. As a result of that, we got about €80 million at the time for the consolidation of maternity and neonatal services in the city.”

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Mr Tony McNamara, CUH CEO

Next month will mark 10 years since the transfer of maternity and neonatal services across Cork city to the CUMH site, outlined Mr McNamara.

One of the next big investments was in cardiac renal services, which involved the transfer of cardiology services from the South Infirmary Victoria University Hospital (SIVUH) to CUH in 2010.

Other developments have included the cancer centre, the construction of new emergency departments and more recently the opening of a new mental health department and children’s department.

Next month, construction will begin on a new radiation oncology department to replace the existing department. It will take two-and-a-half years to build and equip at a cost of €35 million.

Smaller hospitals like MGH and BGH have seen their roles altered significantly to provide many vital services, including enabling the group to meet its waiting list targets, with many consultant staff now travelling from Cork city to the hospitals on a regular basis, Mr McNamara noted.

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Throughout these developments, Mr McNamara has placed an emphasis on sustainability and the environment.

In 2014, CUH became the first hospital in the world to be awarded the Green Flag by international accrediting body the Foundation for Environmental Education.

Mr McNamara documents how this accolade was achieved in his blog, which is published on the CUH website. Thought to be Ireland’s one and only hospital CEO blogger, Mr McNamara uses the forum to highlight his views on healthcare and to update the public on events at the hospital.

“It is something that I enjoy because it is a way of communicating what we’re doing in the hospital here. I’d like to do more but time is a constraint, obviously… I hope to give a sense of what the hospital’s perspective is on important issues in healthcare,” Mr McNamara explained.

“The feedback we get from staff and the public is interesting and informative and sometimes critical. But that’s fine. You have to be open to criticism.”

Recent blog posts have highlighted topics such as outpatient department (OPD) appointments, nursing staff and the trolley crisis.

Yet again, the crisis of large numbers of patients on trolleys in hospital emergency departments (EDs) nationwide has dominated headlines this winter, with little sign of any resolution on the horizon.

Like the rest of the country, Cork has also been struggling to deal with the issue and on 30 January, some 39 patients were on trolleys at CUH.

Mr McNamara believes that no one solution will fix the crisis and that efficiencies in the patient pathway, from community through to hospital discharge, are urgently required.

“When there was a lot more money going into the system we still had problems with patients on trolleys, which suggests to me that it’s as much to do with the processes and systems as it is to do with funding,” surmised Mr McNamara.

“For our part, we’ve implemented about 120 different change initiatives, each of which have contributed incrementally to improving the patient pathway. It’s a measure of the complexity of the challenge that notwithstanding all that, we still face real challenges in relation to patients on trolleys. The suggestion that is often made — that it’s an issue that can be resolved by addressing delayed discharges on their own — is understating the complexity of the whole thing.”

The change initiatives were brought about by implementing the Lean and Six Sigma principles.

Mr McNamara explained that the terminology comes from Toyota in Japan and is an internationally-recognised approach of removing steps in a process that don’t add value.

Furthermore, he believes the 8am trolley count that takes place in hospitals daily should instead be conducted at 2pm.

“The hospital system and indeed the health system is judged by the trolley count at 8 o’clock in the morning, which I think does a disservice to the excellent work that the hospital and health system does. It’s the wrong time of day. The worst time of the day for a hospital is 8 o’clock in the morning,” Mr McNamara stated.

“By 2pm, typically, trolley numbers around the country are reduced by about 50 per cent compared to the 8am count and in my mind that’s a far better measure of the performance of the hospital system.

“I think when you talk to individual patients about their experience, almost invariably the issue comes around to ‘when I got into the hospital the quality of care was excellent’. Access remains the issue and probably the single greatest challenge that we have in terms of the delivery of patient services in our hospitals.”

Recruitment

Meanwhile, hospitals nationwide have also encountered difficulties in recruiting nurses in recent years.  At CUH, thanks to the work of the nursing department and Director of Nursing Ms Mary Owens, nursing staff levels are improving, advised Mr McNamara.

“We’ve recruited about 160 nurses here over the last 12 months. Of those, about 50 nurses are additional and extra to what we had a year ago.”

In his blog, Mr McNamara outlined that offering graduating nurses structured career pathways had resulted in 96 of the 102 (94 per cent) nurses qualifying in 2015 and 2016 remaining at CUH. 

All doctor-in-training posts were filled at CUH this year following the development of a special charter for trainees. 

The hospital has about 190 consultants and all bar 10 are category B consultants, which is incredibly important for patients and income, stated Mr McNamara.

“It’s important for income generation at the hospital here, because we have to generate about €65 million a year in private patient and related income and having consultants committed to the hospital…works for the hospital, works for patients and works for consultants.”

Finances are always an issue and amid ongoing criticism for failing to keep within budget, hospitals are continually trying to balance their books.

Minister for Health Simon Harris recently came under fire from the IMO for directing more money to the National Treatment Purchase Fund (NTPF), resources the IMO believes should be invested in public hospitals.

Providing his own view on the issue, Mr McNamara said that investment is best made in hospitals, provided the hospitals demonstrate a capacity to perform and/or deliver.

“For our part, we outsourced a very small number of patients in 2016. We ended up with 45 breaches out of the many thousands of patients that we treated,” said Mr McNamara.

Guidelines state that no inpatient day cases should wait longer than 15 months to be seen, and anything outside of this is considered a breach.

“We have about half a million patient interactions every year. We have about a quarter of a million outpatient visits and between the many other departments, the scale of that is huge. I think these have to be seen in context,” noted Mr McNamara.

A major public education campaign is required to inform the public of the importance of attending a scheduled OPD appointment, he added.

Around 12 per cent of patients fail to turn up for OPD appointments nationally, Mr McNamara outlined.

“That is a huge wasted resource in the system. In fact, from memory, it’s the equivalent of employing a thousand clerical staff in terms of the cost foregone with wasted time and so on.

“Each patient who doesn’t attend here costs about €125 in terms of the time it takes to pull notes, the clinical staff and so on, and of course that means another patient could have had that appointment.”

Lengthy waiting times for gynaecology OPD appointments at CUMH was one of the main issues raised with Minister Harris during his visit to Cork in January, Mr McNamara revealed.

In a bid to solve the issue, four gynaecologists and €150,000 in new equipment will be provided this year.

Despite calling for more investment in hospitals, Mr McNamara is aware of the importance of primary care and community services in helping to keep patients out of hospitals. He said more community and rehabilitation beds in particular are required.

“I share the view expressed recently that there has to be a much greater investment in primary care in all its facets. Our view is that what is needed is more beds in the community, not necessarily more acute beds. Three per cent of our patients at any one time occupy a third of bed days so clearly there are a significant number of patients in our hospital and in other large hospitals who could and should be treated in community settings.”

Looking to the future, Mr McNamara had no comment to make on Hospital Groups and the South/South West Hospital Group, other than to say it was “a work in progress”.

But he did remark on the importance of providing a hospital system that best serves the public patient and the need to continue to find ways to introduce efficiencies in the patient pathway.

“I think obviously we need to decide what type of healthcare system we want, particularly what type of hospital system we want. I believe passionately in the need for us to reflect on what is in the public interest,” Mr McNamara argued.

“In my view, the appointment of consultants on B contracts in this hospital is a practical manifestation of the sort of philosophy we believe in, in relation to the delivery of healthcare where public patients get substantial access to opinions at the highest level.

“I think there is a substantial resource being expended on the system. I think there’s a significant opportunity using Lean and Six Sigma to get better use for that resource and for ourselves that’s a challenge we’re going to address in 2017, with a number of Lean and Six Sigma projects identified which we feel will improve the pathway for patients and the efficiency with which care is delivered.”

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