Are we productive?

Taima Campbell , RN,BN,Cert.Cl Tchg (Maori),MHSc - Nursing, MCNA(NZ)
Executive Director of Nursing, Auckland District Health Board

On the face of it, increased funding should result in an increased production. Not so if you believe the comments in the media. Recent reports of Auckland District Health Boards financial and productivity have made for good political debate recently, but as with any data, the devil is in the detail.

There is no commonly accepted definition of productivity within the NZ health sector, and this is complicated by a lack of a common measurement base for all health sector ‘outputs'. Although weighted inlier equivalent separations (WIES) are used as a measure for a large proportion of workload (medical and surgical inpatients), this only covers around 50% of the workload of a typical DHB. A significant portion of workload is expressed (and paid for) in other ways. The latter point is important, as the cost of care needs to be measured against the revenue earned to get a complete picture. For example, community services or outpatient costs can't easily be added into the mix because they are not funded the same way as an inpatient stay.

Resource–to–output ratios are a simple equation and a fundamental assumption of productivity. While this assumption is not unreasonable it is not appropriate in situations where services are required to provide the same level of service regardless of output. Key examples of these services are emergency departments and maternity services. Both of these are required to have minimum staffing levels to provide a 24/7 service.

In terms of output, there are a number of ways to measure productivity or throughput. In a recent presentation to the Board, data for the year to date identified that the total number of discharges from Adult Health Services were up almost 10%, meaning more patients (acute and elective) than for the same previous last year. In terms of bed-days (another indicator of throughput) this was up over 3%. The average length of stay (an indicator of both efficiency and throughput) dropped from 3.6 – 3.5 days over the same period last year. In short, what we see in the clinical areas doesn't stack up with the ‘numbers' and we know that the types of patients we see haven't changed – so what is going on?

More work is required to understand where the problem lies and if the system is understating what we do. In order to better understand our inpatient costs in the first instance, there is a great deal of value in our clinical coders being ‘attached at the hip' to medical staff who are primarily responsible for identifying a patients presenting problem(s), thereby generating accurate and timely data needed to recognise the full benefit of the work that we do. We need to maximise our revenue opportunities and be appropriately paid for the work our clinicians do.

The largest staff group in ADHB as a whole, and within ACH, is nursing. When we compare ward nursing FTE with weighted inpatient discharges (medical and surgical, adult and paediatric WIES) the trend over the past three years has, like the overall productivity trend, shown a slow but steady increase. Combined with a shorter length of stay and higher bed occupancy, workloads are high.

None of this means we don't recognise that there is still more work to do or room for improvement. Quite the opposite, there are a number of innovative projects underway to improve hospital efficiency such as the surgical review process; production planning and the after hours model of care to name a few. However, high level, simplistic reports on ‘productivity' need to be interpreted with caution. They can serve as a guide, but our challenge is to measure our own performance and understand where we can improve what we do for the benefit of our population.

( This article was originally published in NOVA, publication of the Auckland DHB Feb. 2007)