The Sunday Times of Malta has gained access to the Johns Hopkins report on Mater Dei Hospital, which cost taxpayers €1.3 million but has been kept under wraps since June 2012. Ariadne Massa gives an overview of the report’s findings.
Patients have learned to manipulate the system to their benefit and as waiting lists at Mater Dei Hospital grew so has abuse at the Accident & Emergency Department.
In an effort to avoid waiting, certain patients have turned up at A&E with symptoms that could perceived as severe enough to justify immediate medical attention, the report established.
Although “gaming of the system” is not common, it still represents enough of a concern as it disrupts normal operations and consumes resources.
“Combined with the internal inefficiencies, this phenomenon causes the continuous clogging of the A&E department and leads to serious breaches of patient safety,” the report concludes.
Another situation that exacerbates the system is the way “certain influential individuals”, physicians and government officials arrange immediate inpatient admissions for “select patients” without legitimate reason, simply to avoid waiting lists.
“These instances not only increase waiting times... but also undermine the morale within Mater Dei and erode public trust.
“The volume of such ‘irregular’ arrangements cannot be accurately determined, but it is thought to be significant across the entire health system.”
These, coupled with a dire need for rehabilitation and chronic care services, are just a few of the serious challenges the island’s national hospital faces.
Commissioned in May 2011 to perform a systems review and needs assessment of the hospital, Johns Hopkins Medicine International provided a blueprint for the island’s healthcare.
Concluded in June 2012, it identified strengths and weaknesses, while providing recommendations for the way forward with an emphasis on clinical, operational and financial practices, as well as accountability.
Following its presentation a number of working groups were set up under hospital CEO Joseph Caruana to deliver the recommendations.
In parallel, the PN government entrenched some key recommendations in the collective agreements signed with the Medical Association of Malta and the Malta Union of Midwives and Nurses in February 2013, paving the path for the other significant changes. Its fuller implementation was scuppered because of an impending election.
Lack of appropriate governance and interference:
To provide acute hospital care and emergency medical services for the entire population Mater Dei requires a secure and reliable supply of medical materials and drugs, sufficient human resources and adequate support infrastructure.
The report exposes how a variety of government entities – including the health and finance ministries, Mita, the Office of the Prime Minister and others – interfere regularly in almost all key management functions at the hospital.
Although this was styled as political interference, in effect this is the way government works, even today, with certain key decisions, such as public procurement and recruitment, coordinated through central agencies.
This situation developed partly because of the previous lack of competent and strong executive management.
Irregular arrangements are thought to be significant across the entire health system
“They have no presence at the hospital, lack healthcare management experience and have to adhere to general government policies and procedures that are burdensome and sometimes outright damaging.”
Johns Hopkins recommends giving the hospital’s management team autonomy, tools and resources to achieve it targets.
It urges that the true cost of service established to accurately measure the hospital’s financial performance.
Limited decision-making authority:
Staffing decisions are handled through lengthy, bureaucratic processes with the hiring process typically taking 14-24 months.
Unpredictable staffing prevents the hospital from implementing new systems and processes, which negatively affects patient care. To circumvent this, hospital management has outsourced certain functions, such as housekeeping, but this is not possible for core functions.
Fund allocation is handled at the Finance Ministry, while the Health Ministry manages the hospital’s budget. The hospital’s leadership has no authority to make purchasing decisions on its own.
Johns Hopkins recommended the government clarify autonomy and accountability within the hospital for staff hiring, as well as procurement of budget-approved resources necessary to prove safe and sustainable care.
Lack of effective fund management:
Large orders are placed in bulk at the beginning and during the course of the year, but often, many are cancelled during the last quarter of the fiscal year once the total paid to the vendor, plus commitments, exceeds the annual budget.
Data reveals a waste of drugs and supplies for a number of reasons: late issuance of inventory items with expiry dates nearing end of life; pharmacy only manages central storage; late notice of out-of-stock items that leads to large orders and expired items; while purchase orders take too long to be issued.
The government should consider redesigning the process to give hospital management full authority over all purchasing functions.
Underused human resources:
Physicians:
Insufficient physician work hours are the single most important factor contributing to the hospital’s waiting lists as most doctors end their clinical session by 1 or 2pm before moving to private practice.
Waiting lists at Mater Dei drive patients to private hospitals where they can see the same doctors almost straight away. The report recognises that eliminating waiting lists would have a profound impact on the entire private sector, “possibly decimating the income” of doctors working in private practice.
The amount of time they spend on direct patient care at Mater Dei needs to be evaluated.
This had been addressed in February’s collective agreement, which paved the way for doctors to work in public hospitals and health centres up to 8pm. To date, the government has still not put this into place.
Nurses:
Johns Hopkins found that the current deficiencies in nursing care are not due to understaffing. On the contrary, preliminary benchmarking of staffing rations revealed that nurse teams in adequately staffed – or even overstaffed – areas had trouble performing the required work.
One possible root cause of inefficiency is the variability of more than 50 different nurse shifts. With job responsibilities limited to patient care on the ward, the report recommends a better working partnership between physicians and nurses to expand the scope of nursing care to higher level, more complex tasks.
It also proposes that Mater Dei should perform a comprehensive nurse staffing needs analysis – this would not only fill shortages but also reduce overtime expenses.