Time to handle with care

Time to handle with care

Engineer and businessman Joseph Caruana assumed the role of Mater Dei Hospital CEO three months ago. He speaks to Ariadne Massa about waiting lists, bed shortage, and being bowled over by the staff’s dedication.

What do you bring to the job?

All my work experience since 1990 has been in private industry in top management positions, which is why I’m here. I have no experience in the civil service, so I’m bringing a totally new way of thinking to this government sector.

Is that hard?

It’s very challenging rather than hard. In the end it’s all about people, motivating and guiding them in the right direction.

Were you disheartened with what you found at Mater Dei?

On the contrary, what has been very positive is the workers’ enormous commitment. The majority give their 100-per-cent and work with passion and dedication.

I’ve realised my role is going to be to guide people in the right direction rather than impose methods... I’m not bringing in magic formulas; I’m just bringing guidance to what is already good.

What are the things that need to be changed?

I think the word is not change, but guided in a different direction where people in their roles understand their responsibilities and accountabilities. I wouldn’t say this is missing but it needs improving.

What are your first objectives?

To focus on getting the basics right. This can be anything from how to take care of a patient in the ward, to how we tackle patients in the Accident and Emergency Department (A&E). We have to make sure everybody, every time, is getting the basics right. This is a matter of refocusing.

What was the reaction of employees?

It has been very positive. I have found cooperation from everybody without exception. I’m very glad. Not that I was prepared for something different, but the way people have collaborated has surprised me positively.

Let me touch on the perennial problem of waiting lists. Figures released in Parliament last month show there were 13,502 pending operations at Mater Dei Hospital. The longest is that of the cataracts, followed by orthopaedics. When you see these figures what goes through your mind?

First of all, waiting lists don’t happen overnight, they grow progressively. We are now shifting our focus from waiting list to ‘waiting time’.

I found out there are individual initiatives both from clinical people within the departments and on a ministry-wide level to tackle these.

My role in all this has been to come up with solutions together with the Foundation for Medical Services.

What is being done tangibly?

At ministry-wide level, FMS has taken up some of the projects and is dealing with the private sector to take on some of these interventions. Internally, the clinical chairmen have come up with ideas to reduce the waiting lists such as using more operation theatres, clocking up more hours in the hospital...

There are positive initiatives at every level. My role is to facilitate this process. We have the tools, the means and the goodwill from most people to make this happen.

Are the doctors on board?

Most of the doctors are on board and I’m very pleased because they came up with their own ideas, which they are implementing in the afternoon sessions in their own departments, while at the same time cooperating with ministry-wide activities.

What has it achieved?

I can only talk about the past three months. We’ve started doing more interventions in the theatres. One section is orthopaedics, where we are using an operation theatre that was previously not being utilised and it’s starting to eat into the waiting list.

We are also progressing to have similar initiatives in the area of cataract surgery... We are devising targets and the goal is to do twice what we do today. I believe it’s achievable with the cooperation of everybody.

When should we start reaping the results?

I believe in the next few months.

In 2008, then Health Minister John Dalli had dubbed Mater Dei a “part-time hospital”...

No, we’re fixing that. We are increasing hours to utilise all the resources. For example, in cataracts, once our internal plans are in place it will be about 75 per cent more than what we’re doing today. All this is thanks to the consultants.

Are we on the way to becoming a full-time hospital?

If we have projects like this we’re on the way. The hospital was always full-time, some working practices were not. Most of these plans have been put forward by individual clinical chairmen themselves and that’s fantastic.

What are your appeals to the other departments not working on such goals?

Take on this example and perpetuate it in all the areas.

Which are the departments of concern?

Our concerns are mostly the waiting lists for cataracts and orthopaedics and we’re doing something about this. I am focusing on these projects to make sure they take off and then we will investigate other areas.

In Budget 2010, €4 million was specifically allocated to address waiting lists. What happened with this money?

When I joined I found this fund was untapped – it’s a godsend. Together with FMS, we are taking it up and starting to farm it out to particular areas...

We’re tapping this especially to reduce the cataracts’ waiting list. Part of the sum is going towards the private sector initiative.

Mentioning the private sector, should the government be investing in expensive equipment when it can sub-contract the equipment of private hospitals? Shouldn’t it be cooperating more with private sector instead of competing directly?

There is already cooperation in some sectors for specialised equipment such as MRI.

First of all, you have to understand that the government has an obligation to assure a level of service, and it’s not always easy to decide what to do in-house and what to leave entirely in the hands of the private sector.

We can only vouch for our capability as Mater Dei and we cannot vouch that in two years’ time private hospitals will be giving the same level of treatment they are giving today. Certain risks cannot be taken.

Do you believe there are risks?

Yes, because at the end of the day the private hospital is there as a business and if it realises that from a business standpoint it’s not doing well, it can stop the service at any time.

We cannot have what we deem as critical services bound to the private sector.

Two weeks ago the Emergency nurses complained about overcrowding at Mater Dei’s emergency department. It said if a simple thing as a van overturns and there are five seriously injured students the department will be thrown into “chaos”. Do you find this acceptable?

We are prepared for major incidents so we know exactly what needs to be done in such situations. Saying we would be thrown into chaos is not correct.

There will be a bigger need to displace people than normal, but there is a proper contingency plan of what should be done in the case of a major incident.

The union threatened, “we’re either going to do something or else act like children and take industrial action”. What is being done to stave off a dispute?

I’m pleased with the union’s cooperation. I’ve discussed the situation and I’ve understood their problems. Their concerns are real and they’re not exaggerating. We discussed plans to alleviate the situation, among which is the provision of more nurses to tackle the workload.

But they are saying there’s a problem of beds and overcrowding...

There’s a blockage somewhere in the process. The bulk of this blockage that is we have a significant number of patients who are waiting for places outside Mater Dei to be freed up for rehabilitation or long-term care. There are initiatives to create more space outside Mater Dei, but these take time.

But are these patients in the emergency department?

No, the bottleneck is created because the patients who need to move to other wards have to remain at A&E because the beds are taken up by long-term cases.

What numbers are we talking about?

The numbers typically reach 75 people. You have to consider that the hospital’s average bed stay is four-and-a-half days, but some of these cases have been at Mater Dei for some 50, 60 or 100 days.

If a patient stays here for 100 days you have to divide this by 4.5, which means one patient is taking up the bed of 22 acute patients.

One thing we’re not doing here that we did at St Luke’s Hospital is we’re not leaving patients waiting in corridors outside wards.

But we have heard of such situations happening at Mater Dei...

Yes, but it’s a rarity. We’re trying to avoid ‘parking’ patients outside wards waiting for admission... We are discharging almost 100 patients a day and admitting the same number, which explains why the problem remains...

The irony is we’re running an acute hospital, but we have cases where the acute patient is waiting for a bed and the person needing long-term care is comfortable in the ward; this is what kills me.

This is something I have been fighting for from day one. We’re trying to make sure that at A&E we’re doing our job properly and discharging the correct patients.

Are you getting there?

I believe so. There are projects to create more bed space. I believe it’s a matter of months.

Wasn’t it a mistake to build a hospital with less beds than St Luke’s?

Bed shortage is a Europe-wide problem. Hospitals overseas are moving towards day surgery or providing treatment at home.

That’s what we need to look at long-term because if we don’t, the demand for an acute hospital will increase. We’re already seeing this happen. We’ve improved but more people are coming.

Ten years ago we had one resuscitation room at St Luke’s in A&E which was enough. Today we have three and sometimes it’s not enough...

The service is better, so more people come and medicine is producing more results, which means people live longer.

If, for example, people experience chest pains they will come to hospital even though they can get the service in health centres and from their GPs, but the easiest and safest solution is to come to Mater Dei.

Another phenomenon is that a lot of people don’t have the time to care for their parents at home so as soon as there’s an ailment they bring them here and leave them here.

Last April, Health Minister Joe Cassar had spoken about the bed remodelling exercise to optimise the use of every bed... what happened to this?

There is a committee at ministerial level working on this. It is identifying bed requirements for the next 10 years, trends of medical conditions and establishing whether our beds will be sufficient to meet the demand over the next decade.

They’re still working on it but there are some interesting findings. For example, in paediatrics we’re fine for the next 10 years because people are having fewer children.

In cardiovascular there is a phenomenon where from a surgery standpoint we’re fine because today a lot of interventions that required a bypass in the past are now treated pharmaceutically, so the demand there is not so great.

What are the other areas where beds won’t suffice in 10 years’ time?

I think in the area of medicinal/clinical services, which would include gastrointestinal problems, kidneys and liver. We need to remodel the beds we have today to take us in that direction.

Prove to me Mater Dei does not have the same problems as St Luke’s but dressed up in a state-of-the-art building?

At face value we have state-of-the-art infrastructure yet the same team. But in practice we’re not tackling it this way.

What we are doing is challenging the way we have been working to try to understand where systems need to be changed. The area we are focusing on most is the aspect of patient care.

Has patient care fallen by the wayside?

No. In theory it should be an obvious practice but as we face our day-to-day tasks there is the danger of losing this. If for example you need a spare part for a machine, what irks you is this, so we waste our energy to try to get it...

We must have the self-control to fix the root cause of the problem...

If we keep patient care at the forefront all the time, from top management to the last person, it will help us prioritise what needs to be done first. It means more communication between all of us within management, between nurses and clinicians, and across the board.

Competent consultants find no problem dealing with competent nurses and vice-versa. Sometimes, the lack of communication originates from insecurity. Our first role as top management is to facilitate the lives of these people – they are the point of our arrow. They are down there in the field.

First and foremost, my role as CEO is to be a facilitator for the experts to get it right every time.

Doctors seem to be kings of health care in Malta, dictating the way things are run and managing everything to suit their pockets, shuffling between public and private practice. Do you feel this is the case?

I‘ve been here for a short while and as an outsider I’ve heard that doctors want to be kings, and that they are only concerned with their private practice.

I am taking an unbiased ap­proach and time is proving me right. If we get things right, whether doctors carry out private practice or not becomes immaterial.

There is enough work to be done here and in private practice for those people who choose to do both. I am focusing on ensuring doctors give me what is expected of them in the contractually agreed period... In most cases we are getting this.

Then again, at Mater Dei we are a village of 4,000 people, so I can’t exclude that we have either drama doctors or drama nurses, but the bulk are not and I can vouch for that.

How much does it cost to run Mater Dei?

About €500,000 a day.

From a solely business, not political, perspective, is it sustainable to continue providing free health care?

From a business point of view it’s definitely not sustainable because you are just pumping out money in an unlimited manner.

Biomedical engineering is changing and we’re obliged to change the equipment; medical techniques are changing too, so we have to train our consultants; the demand is increasing, and life expectancy is going up.

Let’s look at the situation of cataracts. Thirty years ago with a lower life expectancy several people died before needing such an intervention. Today the bulk of our cataract patients are in their 70s. You can’t tell these people you are not going to operate, so you can’t even blame the waiting list issue... We can’t say you’re too old to receive this solution.

How much longer can we sustain the present situation?

It cannot be sustained for very much longer. There are also pressures at EU level to give proper full patient care, and if we want to move in this direction every cent must count. So there is going to be increased accountability in every cent spent.

Today, our data says 35 per cent of patients who come to A&E did not need to come to hospital and they could have solved their problem by going to a GP or a health centre.

However, the way things stand, if they come here we have to accept them and we will only know they didn’t need to be here when we see them.

It is difficult to say how long we can sustain free health care. It all depends how long government finances can carry it, and as time passes it’s going to become more expensive. The sooner we start to address the situation the better.

You can address the problem internally from an efficiency standpoint, but the snowball effect of improved medical services, equipment, and training is much bigger than the efficiency gains we can make.

Comments not loading? We recommend using Google Chrome or Mozilla Firefox with javascript turned on.
Comments powered by Disqus