Gearing up to the opening of new hospital

Kenneth Grech was recently appointed chief executive officer of the new hospital at Tal-Qroqq. He faces a mammoth task to ensure that all is ready by the time the first departments move there from St Luke`s next year. Vanessa Macdonald spoke to him at his office in one of the buildings on the hospital site and found that in spite of his relative youth, he has excellent credentials.

What is your background...

I took up public health as a specialty because it gave me the opportunity to look at the whole spectrum of health care rather than concentrating my efforts on a particular clinical area.

My father, who also is a public health physician, was not enthusiastic about this although he always supported me in my decisions.

After concluding my specialisation in London, I returned and continued my studies in management, where I got an MBA.

In fact since then, there have been a number of clinicians who took up management. This is important, both for me - when I come to recruit people - and also for the service as a whole.

You have been involved in the hospital project since 1994...

I was assistant medical superintendent at St Luke`s in 1994, when the designs for the then San Raffaele Hospital were being drawn up.

I was roped in to review them as they were being produced. At that time, there were concurrently plans for the refurbishment of St Luke`s.

In 1995 I was going to join the Foundation for Medical Services after they issued a call for applications for management positions.

However, although I had got the post, I did not take it up as it was just before the 1996 elections when there was a temporary moratorium on appointments and promotions.

Instead I went back to the health department head office, mostly involved in institutional health.

It was then decided to review the whole project and my colleagues and I drew up a number of reports so that the government at the time could choose which option to go for.

It was decided to change the hospital from a 480-bed specialist hospital into an 850-bed acute general hospital, and once the decision was taken, all the previous work had to be reviewed. And of course, St Luke`s role was also changed completely.

I was made responsible for the new medical brief, which took a year and a half to draw up, and which was completed in September 1998 - when another election was held. In the interim activity on site had slowed down, although it never stopped.

The new Nationalist government reviewed the brief and thankfully endorsed it with a few amendments. This means it has been more or less endorsed by both governments.

The actual design work then started. Skanska were recruited as designers and work commenced. Design work is still ongoing, although all the preliminary department and room layout designs are ready.

Now we are down to what they call the shop floor drawings, involving all the mechanical and electrical installations.

The advantage of having a "design and build" contract was that construction work went on in parallel and we did not waste time waiting for designs to be ready, for example, work could continue on the larger car park etc.

In the meantime, I was taken on by FMS, following another call, as head of institutional operations, responsible for all the health planning and medical aspects of the project. I set up a team and subsequently also became the client representative, that is, responsible for the overall project on site.

You are now the head of what is ultimately a business, even though it has social implications, with a turnover of Lm50 million a year and yet you have never run a hospital...

It depends on how you look at it. First of all I was at St Luke`s for over a year and up to recently most management decisions and administration used to be made at head office in Valletta, where I spent over six years.

So I was directly involved with the management not only of St Luke`s but also of all the other public hospitals. Whether I can handle it... I think so as I would not have accepted the post otherwise. Apart from this experience, I also have numerous contacts with hospitals abroad.

Also, one must realise that my tenure as CEO would mostly involve preparing St Luke`s and the new hospital for the transfer of services and the setting up the necessary structures within a very limited time-frame. And therefore what was needed was someone with an in-depth knowledge of the new hospital project and of St Luke`s.

It is a challenging, daunting task - use whatever adjective you want - but it is not impossible. I believe that if you have the right people in the right places, it can be done.

One of the biggest perceived problems is negotiations with the unions and professional associations who are all going to have to be persuaded to accept an autonomous structure and totally different working practices, if we are to avoid transferring the problems at St Luke`s to the new hospital.

Let me start by saying that I do not view negotiations with the unions as a stumbling block; I see them as a springboard for change.

Both the unions and the health authorities hope that it will be an opportunity for change. What we have to agree on is the direction of that change. There is political agreement on the concept of autonomy, as well as within the health department and ministry, and even the unions have never came out against it.

I am not saying that it is going to be an easy task, quite the contrary, as a lot of work practices need to change and it will need a completely different mentality.

However, when the reform of the health sector started in 1993 and 1994 the unions were also clamouring for change.

However, they have an obligation to safeguard the rights of their members, that is their role, and I hope that they do it well... I would not want to have a workforce that does not have good working conditions and is not happy.

Haven`t things gotten off on the wrong foot? Negotiations were supposed to have started last July and still haven`t...

You have to understand that we had to prepare ourselves - as did the unions - so although some time was lost, hopefully, the time will serve us well, as we now have clear objectives. Hopefully the time will not have been lost but will be time gained in the long run. Negotiations will start soon, although there is no definite date. I think we are all eager to get going.

Many of the problems basically get down to remuneration. If the out-patients department is open longer and operations were held throughout the day, won`t it mean more man hours and hence more money?

It is not a sine qua non. Staff do not want their working conditions to change only in terms of remuneration, but also in terms of working environment, support structures etc.

I think these aspects are just as important as the pay packet. The salaries will come into the negotiations but everyone knows that the government has certain financial constraints and we all need to be a bit realistic as to what can be achieved in practice.

We are hoping to be able to introduce systems which will not necessarily mean they will work longer hours - their hours are already recognised as being too long - but will mean a more flexible way of working, although details are not yet available.

Is the hospital looking at other ways of raising revenue, besides its allocation from the government?

We haven`t yet looked into it in detail but even when drawing up the medical brief, we identified areas which could be sources of revenue generation, both in terms of service, say to private industry or to foreign patients, as well as in support services.

We already have a pretty good idea of where this could be done. We could lease out retail and other areas, such as to a florist or the car park, for example, but, linked with our objective of getting strategic partners from abroad, we would also be able to attract patients and services from abroad.

We have always had links with other hospitals abroad and are now working on formalising them, setting up strategic partnerships.

This will bring us into a network where we would have access to training and exchange programmes, but also very importantly, we would be able to link up with them for benchmarking exercises, performance indicator programmes, accreditation programmes...

The new hospital cannot work in isolation. Hospitals abroad can always compare their performance with other hospitals in the same region, in both clinical and non-clinical areas. We have to do the same.

Within St Luke, there are already benchmarking and audit exercises carried out both departmentally and individually. I would like to see that formalised, giving support to individual initiatives, as these exercises need funds and resources.

Back to the idea of revenue generation, will the hospital sell services to private patients? For example, the UK government is sending NHS patients for treatment abroad where it has excessive waiting lists..

The new hospital certainly has the capacity in terms of operating theatres and investigative functions. The problem is bed capacity, but it is certainly something we are looking into. Hopefully in the future we would be able to attract patients from the EU, the Middle East and even Northern African countries.

You mentioned bed capacity. One of the problems at St Luke`s was social cases. Presumably these will not be transferred to the new hospital...

The new hospital does not have the capacity to deal with social cases whether in terms of bed numbers or in terms of space. We physically cannot put a bed in between other beds the way we can at St Luke`s.

It needs to be looked at carefully and will hopefully be part of the overview of the future of St Luke`s. This issue doesn`t fall under my direct responsibility as it also involves social services and other departments.

I certainly hope that it is not a problem that will land in my lap.

You have also been involved in drawing up the migration plan. Do you foresee any problems?

As long as it is very well planned it should go smoothly. We have the completion date of the project in terms of Skanska`s contractual obligations with FMS, and we know when the building will be ready for occupation.

What we now need to do is to dovetail those dates to the transfer of the individual departments and services.

We are recruiting migration specialists who will be looking in detail at these matters to the point that there will be dates for the move of each and every service. These would be real dates, which will need to be adhered to.

Won`t there be a lot of overlap?

No, not a lot but some. That is a reality that we will have to manage very carefully, keeping patient safety very much in mind. There will be some overlap in terms of services being offered from both sites, but not of the same departments or specialties.

Accident and emergency will probably be one of the last departments to be transferred, but its function will be in place in the new hospital from the very first day. So if, for argument`s sake, the paediatric department is in the new hospital, its emergency and admitting function will also have to be in place at the new hospital.

We will be looking at a huge communications strategy, both internal and external. Staff will need to be informed in detail about what is going on, and the public will need to know where to access services. That is actually something the migration specialists will be looking at.

It is not just a case of picking up something and taking it to the new hospital, but also of training, getting the staff used to the new environment, the new equipment, training them on any new procedures or protocols. This is why the post I occupy was issued now, so that all this can start as soon as possible.

What will the role of IT be in the new hospital?

At the moment we are drawing up an IT strategy where our current IT needs are being analysed.

The systems will be open ones, not closed ones where our systems will be able to be integrated with the rest of the health service. We will have recommendations on how to link up not only with other hospitals and health centres but also with private doctors.

We are still studying whether patients` records will be kept electronically, however, it is yet very complex and costly. Only a few hospitals abroad work in a totally paperless hospital environment, mainly private ones in the US. When the prices go down, we could consider adopting this strategy.

Test results will be logged electronically, for example, blood tests, which now mean filling a form and getting the result on a form, would be requested electronically and the results issued electronically. But staff will have to become accustomed to these systems.

It was also decided to have a fully digital X-ray system within the hospital, which means that we will have no X-ray films. This has huge implications, both on the radiology departments but especially upon the clinicians and wards. We will also install financial control systems including stocks, payrolls, pharmaceuticals, which leads to more accountability and less waste.

This will also make it easier for clinical audit...

Yes. One of my top management posts will be responsible for quality assurance. However, it will not be a centralised function. Management will provide support for audit to be carried out at clinical levels, by nurses and clinicians. I have to have in place audit trails and audit programmes in order to be able to monitor performance and progress. I will also need to have performance indicator programmes to be able to monitor my own processes.

Patients themselves misuse and abuse the system, whether using the emergency department inappropriately or because of high expectations...

This also definitely needs to be tackled. When we drew up the medical brief, 35 per cent of those using the casualty department should not have gone there in the first place. Now that has gone down to around 15-20 per cent, a good sign. But we have to push it further, although it would be impossible to get the rate down to zero.

The problem is that once the service is available, it will be used and abused, especially if it is free. The mentality of the Maltese population in terms of accessing health care needs to be more informed, but this applies to all social areas, not just healthcare.

Hopefully the new hospital will serve as a catalyst for change in this regard as well. When you see something new you might think twice about abusing it, even in terms of looking after the public areas and keeping the environment clean.

What do you think will be your largest challenge?

What I would like to see is for all the staff to feel proud to work within the hospital, which is something that we may have lost along the way. And to do that, we have to have staff who are committed to their work and to the organisation, which will mean providing them with the necessary support.

I see my role as providing systems for core operations to function efficiently, and then afterwards to monitor them. Changes of work practices and mentality will then follow.