What Really Mattered in the End
May 10, 2019 -
Mr. J. A. McNamara
In his book “What Really Matters in the End?”, Atwal Gwandi, a surgeon at the Brigham Hospital in Boston, reflects on the challenge of caring for his sick father and raises deeply important questions as to what should be the key issues to guide us through life.
As I leave the position of CEO of Cork University Hospital after 27 years, I am given to reflect on this question in the context of the hospital and its future.
The public, through their taxation, invest substantial money annually in hospitals such as CUH, which spends €370m every year (€1m per day) and they are entitled to expect a service that befits this funding commitment. Those expectations are ever changing, as a result of increased awareness of new treatments, therapies, technologies and expertise that are communicated through the internet, social media and other means.
On the other hand, the capacity of the health system to deliver on those expectations is constrained by, for example, available resources, adherence to provisions in employment contracts, shortcomings in healthcare delivery systems and sometimes inertia. In addition, requirements to adhere to standards set by outside agencies such as HIQA, external accreditation bodies, regulatory bodies and legislative provisions place considerable strain on resources but provide a necessary assurance to the public of conformance to standards.
CUH is the largest and most complex hospital in Ireland with over 40 different specialties and over 100 different departments employing 4,200 multi-professional staff. This complexity is reflected in the fact that there are many tens of thousands of moving parts in the functioning of the hospital on a daily basis in the form of decisions made in many different domains, for example, on the treatment and provision of care for over 500,000 patient visits to the hospital annually, preparing 1,000,000 meals per year and the prioritisation and allocation of resources.
Consistent with the principle of “singular accountability” as CEO, I am responsible for every one of those actions undertaken by all staff in the course of their work.
The scale of the challenge is to deliver care of a consistently high quality to every patient and to do so in a way that is personalised for each individual within the level of approved resources. The greatest resource that CUH (and every other hospital) has is the commitment and professionalism of its staff whose values and beliefs translate into compassionate, empathetic care on a consistent basis.
In support of staff who deliver care, whether in the Catering Department or in the Neurosurgical Department, it falls to hospital leadership to allocate resources equitably, in recognition of the contribution made by every Department to patient care. The challenge to maximise that resource, demands rigorous identification of cost reducing opportunities and using scientific techniques such as Lean Management, waste is increasingly being reduced and in the case of CUH, the attainment of an annual saving of 3% efficiency using Lean Management would release €12m in efficiencies for redistribution in the hospital.
These are not abstract issues but are in fact the reality faced by CUH (and other hospitals) on a daily basis. It is a privilege to be in a position to work with colleagues who make a meaningful and quantifiable difference to the health and quality of life of our patients and by extension to their families every day of the year. It follows that there is a significant responsibility on hospital leadership to advocate in the public interest and in the hospital interest for the resources required to achieve quality at a level that is acknowledged as equating with best international standards. Patients need to know for example that if they are being treated for cancer, the protocols that govern their care accord with best practice and that they have access, if available, to drugs that are being used in leading edge international clinical trials.
The development of comprehensive programmes in each of our 40 different specialties that provide quality care, is a significant responsibility that demands vision, ambition and energy from many levels of leadership in CUH. Failure to meet these challenges and to develop the range and complexity of services for our population would represent a failure to society and to those in society who need comprehensive medical care.
The creation and maintenance of a culture that is based on values such as empathy, the need to offer hope to patients, supporting innovation and change but particularly demonstrating respect helps to define the soul of the hospital. It is a given that patients should be treated with respect, but it is also critically important to acknowledge the need to respect each other as colleagues and to respect the environment.
CUH is now recognised as a comprehensive multi-specialty teaching hospital that has the capacity to gain international recognition for its work in key niche services such as cancer care and cardio-vascular medicine. In this regard it is one of perhaps three hospitals in Ireland that has the critical mass and the expertise to achieve this goal and the attainment of this level of international recognition will require continued differentiation from other hospitals which will take several forms.
In the first instance, it will require the development of formal agreements with international leading hospitals and this has commenced with CUH having a formal arrangement with The Christie Cancer in Manchester which is recognised as one of two leading cancer centres in the UK.
In addition, there is a need for continued development of the academic base in CUH in niche clusters of services and a broadening of clinical trials which give patients access to the very latest drugs that are being trialled by manufacturers and work in both these domains is well advanced in CUH.
The recent designation by government of CUH as one of two Trauma Centres in Ireland marks a very important commitment to the development of many services that are related to the management of trauma and this will increase the critical mass of expertise in those services to enable the hospital provide improved services to our population over the medium term. There is little doubt that there is a gravitational pull towards larger hospitals that is dictated in part by the attractiveness of those hospitals to clinical experts who have options as to where they wish to work and are attracted by a broad case mix, an academic focus that sustains innovation and a culture that makes hospitals such as CUH a good environment in which to work.
In the final analysis we are but custodians of the roles we fulfil in life and it is a remarkable privilege to be charged with the responsibility of contributing to public life and to the delivery and development of something as critically important as healthcare which impacts on everybody.
The opportunity to shape and define the values that underpin the delivery of quality care to patients and to help create the teams and the environment in which that care is given to each patient individually and empathically, are deeply important and will I hope endure in the reputation and legacy of CUH.
The delivery of personalised care for every patient that is driven by those altruistic values, will I hope, be enduring and represents perhaps what really mattered in the end.
Tony McNamara,
Chief Executive Officer,
Cork University Hospital