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Article Article April 5th, 2017
Health

The power of programme management

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In 2012, the New South Wales govt set up a Programme Management Office to improve health care

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The NSW Health PMO helped local health districts to drive reform in their own organisations

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NSW's PMO team helped deliver clinical improvements, showing that it's not all about finances

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Residents of New South Wales (NSW) in Australia have got a good thing going. From wineries to rainforests, sweeping mountains to the urban wonderland that is Sydney, theirs is a state that often prompts envy and admiration in equal measure.

Its state government, though, is not without its challenges. Partly, that's to be expected - somewhere that's a little larger than Texas will always have issues cropping up and problems to allay. These include the challenge of maintaining high-quality services and constraining growth in public spending, which was a key priority for the NSW Government in 2012.

As part of its response, the state required big clusters of government services to have their own programme management office (PMO). A PMO's purpose is to track, monitor, and report on how the service intends to implement savings programmes so that they remain within tightening budgets. In the field of healthcare, however, their tasks also included tracking a range of clinical improvement initiatives.

The last PMO to be set up was the one for NSW Health. It was tasked with helping districts to plan and monitor initiatives that were designed to improve the quality of care and so reduce unplanned readmissions. Under the leadership of its director, Heather Hukins, it also sought to reduce patients' average length of stay by improving discharge planning, introducing new models of care for acute and chronic conditions, and reducing unwarranted clinical variation. This was so that people across NSW received more consistent, clinically appropriate care.

NSW Health's PMO was different from the ones already up and running elsewhere in the state government departments. "NSW Health wasn't that interested in driving savings or anything else in a largely centralised way," Hukins explains, "and so it was a very different animal, set up for a different purpose. It was really to help local health districts to drive reform in their own businesses."

Health check

A quick look at the numbers showcases the scale of NSW Health's operations. In 2012, when its PMO was established, NSW Health had an AUD18 billion budget, including around AUD1 billion of capital spend, and there were 1.7 million acute patient admissions in 2012 and 2.6 million emergency department presentations. Today, there are 230 public hospitals, as well as a range of community health and other public health services that are provided through devolved local health districts - established as part of a wide-ranging arc of health governance reforms that delivered greater local autonomy.

Rather than being a centralised command and control system as it had been before, NSW Health was divided into locally-governed health districts. There are 15 in all, each with its own local board. There was also a range of other health-oriented entities - such as the Clinical Excellence Commission, the Agency for Clinical Innovation, and other independent organisational units. After about a year, NSW Health was more of a loosely confederated network of businesses delivering health services purchased by a central funding body than one single department.

Reaching out, building up

From day one, the PMO had few resources to draw on - it took four months to bring another team member on board - and this meant that Hukins had to prioritise specific areas of activity. "We made a decision early on to help the people who wanted to be helped, usually because they had a problem that we could help them to solve," she recalls.

"The PMO aligned our team and function very early on with a group called the System Relationships and Frameworks Division. This was the division of the Ministry of Health - the central agency in the health cluster - that administered the funding agreements with the local health districts. I thought they were the most influential people in the business, and they were very well regarded. With this in mind, I made a point of standing next to them whenever anyone was looking, so we could be most closely associated with them rather than with the finance function. This meant people understood that our work wasn't about constraining spending but about empowering districts to do what they needed to do."

This approach soon bore fruit, and it wasn't long before the sceptics were won over. "Although we initially focused on the districts that most wanted help, on my first day I set myself the goal that I would be invited to present to each of the local health districts within my first year - it ended up taking 13 months, but only because of a scheduling glitch with the last one," recalls Hukins.

Some early-adopting districts either needed to solve a clinical problem or they were under financial pressure. So the PMO team was on the road a lot, spending time in the districts to help them shape their reform agenda and write robust plans, and subsequently to help track and monitor those plans. "The first three that got on board because they needed help, we just desperately over-serviced them to make sure that they were deeply satisfied," she explains.

"The PMO was also able to help them drive genuine objective success quite quickly, and we were fortunate that some of the credit stuck to us. This brought enough of the rest of the districts on board so that we had a critical mass, which enabled us to cajole everybody else into joining in. So it was a relatively organic process - the last few hold-outs were concerned that they were missing out on something good, so it was a relatively easy process."

The PMO deliberately kept processes simple, and focused on clarifying accountability for delivering each project and each individual milestone. They tested the quality of each plan by getting key stakeholders together to check if the project was set up for success, was sequenced appropriately, and had considered risks, among other issues.

The team at full size was five people, and after two years it was supporting just under 2,000 projects across the state. Although each district had its own local character, there was some similarity across the portfolio in different places. The PMO put a fair amount of effort towards trying to join things up. In order to deal with recurring issues, they built “Exemplar Roadmaps”, which put some scaffolding in place to guide people in local districts.

Small team, big impact

Since the PMO system has been in place, NSW Health has come in on budget every year - a big change from the overspends of some earlier years. "I'm sure this is due in part to the fact that local health districts were able to track, monitor and report on the initiatives they were driving," says Hukins.

But their impact did not finish there, it transpires. The PMO was also able to help the NSW Health system through a tremendous period of change - not only cementing the localisation reforms but also the kind of systemic reform programmes that came out of organisations like the Clinical Excellence Commission. "So I believe we had an enormous impact on clinical outcomes for the population of the state, as well as being guardian of the future in relation to constraining spending," she says.

Although Hukins has since moved on - she now advises governments on delivering their policy priorities - she says that the trajectory has remained positive. "It was an interesting journey, and I'm delighted that it continues to go from strength to strength," she concludes.

Certainly, their success shows that a PMO's impact does not need to be limited to matters financial. That real clinical improvement has stemmed from the efforts of the PMO team is a testament to the ability of programme management to power improvements large and small across a variety of metrics. Impact assured - and for the long term.

 

FURTHER READING 

Written by:

Trish Clancy Managing Director and Partner, Boston Consulting Group
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