Tuesday, April 07, 2009

Lies, Damned Lies, Statistics and Corruption – What is Going on in Victoria Health?

Over the last week or two there has been a very nasty story emerging from the Victorian Public Health System. It seems it has more than its fair share of fibbers!

This report provides the initial flavour of what has been going on.

Buck stops with me, says Health Minister Daniel Andrews

Article from Herald Sun:

Staff writers with AAP

March 31, 2009 10:15am

STATE Health Minister Daniel Andrews says he will take full responsibility as details of falsified public hospital waiting lists emerge.

At a meeting with the state's public hospital chairs yesterday Mr Andrews put all hospitals on notice that inaccurate reporting would not be tolerated.

Mr Andrews announced Victoria's public hospitals would be subject to random audits which may include data on elective surgery and emergency treatments after an independent audit revealed the Royal Women's Hospital (RWH) had fudged its figures on elective surgery wait times.

"I take responsibility for these matters,'' he told ABC radio.

"It's been occurring, it should not have been occurring and I will not hesitate to act against any further evidence that's put forward.''

He said auditors had found no evidence to indicate senior management or the board knew about the practice which dates back to 1998.

A minister-appointed delegate will now join the RWH board to oversee the implementation of improved hospital reporting procedures.

Mr Andrews warned manipulating data would not be tolerated.

"Every single hospital is on notice this is inappropriate behaviour and I will not tolerate it,'' he said.

"All the chairs of the major hospitals came to my office yesterday... and I made it very clear to them that it is my expectation and the community's expectation that they record their data accurately and in turn they report their data accurately to the Department of Human Services.''

The $40 million bonus funding pool available to high performing hospitals has also been scrapped.

Much more here:

http://www.news.com.au/heraldsun/story/0,27574,25266415-2862,00.html

As if this was not enough it seems there were more than just one hospital involved and that the issues were genuinely systemic.

Hospital waiting lists scandal grows

  • Nick Miller and David Rood
  • April 1, 2009

MORE Victorian hospitals have been dragged into the waiting list rorts scandal, after government records revealed suspicious anomalies across many health services and a whistleblower described how the Austin Hospital was allegedly falsifying data.

The records, obtained by the state Opposition under freedom of information, implicate the Austin Hospital as the most likely to have improperly manipulated surgery waiting lists.

But they also point the finger at the Royal Melbourne, the Angliss, Royal Children's, Sunshine and Western hospitals.

Most of these hospitals were part of a government scheme that gave hospitals extra money for reaching waiting list targets.

At the Austin and Royal Melbourne, more than a third of patients were transferred from a secret "not-ready-for-care" waiting list to the official waiting list only a couple of days before their operations.

The Opposition said this was strong evidence the hospitals were "warehousing" patients on the secret list to make waiting times for surgery appear smaller.

An audit last week found the Royal Women's Hospital was using this method to misrepresent waiting times.

In other data, some hospitals reported unusually high levels of "patient-initiated deferrals" — patients who supposedly decided they were not ready for their operation.

The Royal Women's, which has admitted rorting the system, reported an incredible 99 per cent of deferrals initiated by the patient rather than a doctor.

Even more revelations here:

http://www.theage.com.au/national/hospital-waiting-lists-scandal-grows-20090331-9iaz.html

While I often have a different perspective from the AMA this commentary I think is on the money as far as it goes.

Nothing but the truth

  • Doug Travis
  • April 1, 2009

Patient treatment is being compromised as hospitals try to work the system.

THE Victorian community has been dismayed to learn that a trusted institution, the Royal Women's Hospital, has been falsifying and manipulating reporting data. Yet, as the Victorian Government acts to stamp out the perverse incentives that have led to data manipulation, the Commonwealth is ready to impose reporting requirements across the health system that may reinvent those incentives.

Federal Health Minister Nicola Roxon should therefore be watching this story unfold and considering the lessons learned.

Good information is the lifeblood of good health care. For an individual patient, the more a doctor knows of his or her history and diagnostic profile, the more likely a good outcome. To protect the health of the community as a whole, we need accurate and complete reporting. Manipulated and falsified data means that Government cannot adequately plan for the future health needs of Victorians.

Presenting a rosy picture hides the problems in our health system. For example, because of overstated successes, governments have held back on tackling bed shortages in Victorian hospitals. These shortages have become critical in recent years, meaning that bad data is compromising safe and effective patient care.

Other hospitals may be found to have manipulated data. AMA members suggest that several hospitals have set up systems that appear designed to meet key performance indicators (KPIs) rather than good patient care, such as creating short-stay units attached to emergency departments. The definitions of "time to care" are tweaked in some hospitals to produce a more favourable KPI outcome.

.....

I hope Roxon is watching the Victorian health system closely to see what perverse incentives can do to resources, planning and quality care. We must report accurately and truthfully to be accountable to the community.

The bottom line problem is that the truth can be embarrassing. Let's address the problem, not by spinning the statistics to avoid embarrassment, but by treating enough patients, so that the truth does not embarrass us.

Doug Travis is president of AMA Victoria.

Read the full commentary here:

http://www.theage.com.au/opinion/nothing-but-the-truth-20090331-9i8j.html

There are a range of lessons here:

The first is not to stand between hospital administrators and an extra bucket of money where the money can be had by providing a statistical report. This sort of perverse incentive will always ensure dodgy data.

The second is that if you are to reward Key Performance Indicators (KPI) you design them to be derived from operational systems that there is a very strong incentive to have being accurate – i.e. systems where the information gathered matters not only to the person collecting and recording it but to those further on in the patient’s care chain. They will soon complain if they are seeing rubbish being entered as they are relying on accuracy to get their treatments and care right.

The third is that, ideally, all KPIs are captured totally automatically, and invisibly, as a by product of the delivery of patient care. That way there is way less capacity for any fraud and information deception.

Of course this third assumes we have high quality, joined up, integrated systems in whatever facility we are funding. Sadly I suspect this is not the case and until it is the capacity for the odd manual fudge will exist. Until an e-Health nirvana arrives the best that can be done is to ensure that the intrinsic design of KPIs makes them fraud resistant.

As I have said previously, it is not the hospital staff who are really to blame here. It is the designers of the incentives and those who choose to fund the system in ways that put the staff under stress.

David.

2 comments:

Anonymous said...

Don't be so harsh David,

the huge layer of hospital management has been managing hospitals at least as well as the managers in the financial system. Maybe we should also have some transparency about salaries and bonus payments inside the health departments as well.

When are we going to return hospitals to the control of health professionals? Surely the current management strategy is a clear failure.

Dr David More MB, PhD, FACHI said...

On your third paragraph - could not agree more. What I was trying to say is that the blame is to be sheeted home to the system designers - not those working in the system. The issues are systemic and need system change as you suggest.

David