Mater Dei Hospital

A Better Social Return

John Dalli
30 th October 2013

Observations and Recommendations about the Management and Operations of Mater Dei Hospital to develop a patient centric culture to ensure the provision of a health care service at an acceptable level of quality but at the least possible cost. And some observation on the health system in Malta.

Report on Mater Dei

John Dalli

Report on Mater Dei

John Dalli

Table of Contents
FORWARD...........................................................................................................................................................4 SUSTA !A" # T$ OF T%& %&A#T% S&CTOR......................................................................................' (AT&R D& %OS) TA#..................................................................................................................................* (A!A+&(&!T.................................................................................................................................................., JO%!S %O)- !S R&)ORT 2011................................................................................................................... F !A!C&............................................................................................................................................................../ !FOR(AT O! T&C%!O#O+$................................................................................................................11 %U(A! R&SOURC&S....................................................................................................................................12 !0&!TOR$......................................................................................................................................................14 P ROCUREMENT ................................................................................................................ 14 P ROCUREMENT OF S ERVICES ............................................................................................ 15 O UT OF S TOCK P HARMACEUTICALS ...................................................................................16 O THER C ONTRIBUTING F ACTORS ......................................................................................17 I NVENTORY IN H OSPITAL ..................................................................................................18 E NHANCING C OST E FFECTIVENESS IN THE S URGICAL D EPARTMENTS .....................................19 C# ! CA# )RACT C&S.................................................................................................................................21 T%& #&0&# OF CAR& S % +%1 "UT T S D SOR+A! S&D.........................................................21 WA$ FORWARD..............................................................................................................................................23 R EFOCUSING THE R OLE OF THE F OUNDATION OF M EDICAL S ERVICES ...................................2 A CHIEVING !B EST " IN "C LASS # P ATIENT C ENTRIC $ UALITY S ERVICES P ROVIDER ......................24 D EVELOPMENT OF A !M ANAGEMENT # I NFRASTRUCTURE .......................................................26 E VOLVING H OSPITAL S ERVICE D ELIVERY INTO A H IGH V ALUE A DDED N E% E CONOMIC S ECTOR ..................................................................................................................................... 27 R&T% !- !+ W&##!&SS 2 T%& FUTUR& OF %&A#T%CAR&.....................................................2. T%R&& ARU) S)&C A# STS S%AR& T%& R 0 S O! OF T%& FUTUR& OF %&A#T%CAR& D&S +! 3 %TT)455WWW.ARC%DA #$.CO(543/./.5.........................................................................2. L OOKING A HEAD & A F UTURIST ' S V IE% OF H EALTHCARE ( I AN M ORRIS " HTTP &)) IANMORRISON . COM ) LOOKING " AHEAD " A " FUTURISTS " VIE% " OF " HEALTHCARE )..................28 A PARADIGM CHANGE ...................................................................................................... 28 I NNOVATION ................................................................................................................... 28 A S(ART SO#UT O!....................................................................................................................................31 A %&A#T% S&R0 C&S &CO!O( C S&CTOR.......................................................................................32

Report on Mater Dei

John Dalli

Forward
This review is a snapshot of the situation in Mater Dei Hospital. It is not an in depth anal sis of all the issues !ut it "ives an idea of the underl in" causes of the d sfunction in this i#portant service which is vital for the Maltese $eople. This review is not intended to stand in %ud"e#ent or to point fin"ers. It is a state#ent of facts& a definition of a pro!le# which is the first lo"ical step to correct and solve an pro!le#. 'e can develop a first class health service that will not onl provide a cuttin" ed"e health care service to the Maltese $opulation& !ut that will also e(pand into a thrivin" econo#ic sector that ensures the sustaina!ilit of the health service and that increases the econo#ic well!ein" of the countr . I than) the Minister of Health& Dr. *odfre +arru"ia and the $er#anent Secretar Mr Joseph Rapa for the openness with which we discussed all the issues that arose fro# ti#e to ti#e. I also than) the consultants that have !een assistin" in the various areas within the hospital, Mr. -harles *ri(ti . -linical Mr. John A!ela . +inance Mr. Mar) Sa##ut . IT Mr. Michael +arru"ia . $rocure#ent and Inventor Mana"e#ent. I also than) the various personnel at Mater Dei and within the Health Ministr who spent ti#e with #e discussin" the #an issues that were raised durin" # review.

John Dalli 3/ st 0cto!er 21/3

Report on Mater Dei

John Dalli

Sustainability of the Health Sector

The #a%or issue in the health sector throu"hout the world is the sustaina!ilit of the health s ste#s that have !een developed over the past decades and that are !ased on solidarit . Scientific pro"ress in resultin" in !etter #edicines and procedures that are increasin" health costs even #ore as patients e(pect the !est that is availa!le. The !etter cures and care co#e at increased costs& while& coupled with a !roader covera"e of the population resulted in an a"in" population that is increasin" the de#and for health e(ponentiall . However& resources are li#ited& and therefore s#art solutions need to !e found to finance and deliver the health s ste# that the population e(pects. 'e own it to future "enerations that the can also rel on a hi"h 3ualit & accessi!le health service. The #a(i# has to !e that announced ! the 'orld Health 0r"anisation, Health is a state of complete physical, mental and social well being and not merely the absence of disease or infirmity. and Hospital management has a responsibility to the community to provide health care service that is at an acceptable level of quality but at the least possible cost. A s#art health deliver should !e !ased on an appropriate #i( of prevention& self care& co##unit care& pri#ar care& and a cost effective acute patient centric tertiar health s ste#& supported ! ade3uate reha!ilitation and "eriatric facilities. This report focuses on Mater Dei Hospital& and the restructurin" that #ust !e done so that proper care is "iven within an ade3uate ti#e fra#e at an efficient cost.

Report on Mater Dei

John Dalli

(ater Dei %os6ital

A review of the processes and operations which have !een allowed to develop in Mater Dei over the ears shows a tale of ineffective #ana"e#ent resultin" in inefficienc and waste. It reveals a state of pla where coherent political and ad#inistrative leadership is stri)in" ! its star) a!sence. The result is a state of anarch where ever sta)eholder within Mater Dei Hospital 5MDH6 has esta!lished its own 7territorial8 rules at the detri#ent of a patient centric 3ualit health care e(perience of e(cellence across co##unit care& acute& reha!ilitation and outpatients value chains. 'hat is distressin" of the state of pla is that there is no rational reason of wh Malta8s health s ste# . with MDH& currentl & the )ernel of such a s ste# . is in the level of disarra that it is. Malta& has onl recentl & invested #illions in a new acute hospital& sophisticated and leadin" ed"e health technolo" & and is currentl in the final sta"es of co##issionin" a state of the art oncolo" hospital. This invest#ent constituted a uni3ue opportunit for the political& ad#inistrative& and health service professionals and service providers to co#e to"ether and re9desi"n the paradi"# for health service provision in Malta. +ro# first hand e(perience I can state that the #ain underl in" reason for the invest#ent in the :ew Hospital was this paradi"# chan"e. That this has not happened is scandalous.

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John Dalli

(ana7e8ent
The sin"ular #ost disconcertin" ele#ent that co#es out fro# the review is that no invest#ent was #ade to e3uip hospitals& which are co#ple( or"anisations& with e(perienced talented #ana"e#ent . at all levels and in clinical as well as ad#inistrative positions. This report is une3uivocal, an refor# of MDH and related hospitals within the health service deliver value chain will fail unless *overn#ent is read to invest in a co#prehensive and e(tensive #ana"e#ent infrastructure across senior and #iddle #ana"e#ent levels in ad#inistrative as well as clinical positions. Malta has li#ited& if at all& e(pertise in hospital #ana"e#ent and no effort was #ade to i#!ue the hospital with the specialised #ana"e#ent s)ills re3uired to or"anise and run health operations li)e Mater Dei. +ro# personal e(perience I can sa that an effort was #ade in 211<=> with Johns Hop)ins& a reputa!le ?S hospital to participate in the reor"anisation and #ana"e#ent of the hospital with the o!%ective of overla in" a professional s ste# in Mater Dei and inse#inatin" an international Health Service as a new econo#ic activit for Malta. This initiative was dropped in 21/1 !ut Johns Hop)ins was later as)ed to produce a report on Mater Dei with reco##endations 5see !elow6 Deficient #ana"e#ent is e(acer!ated ! the continuous political involve#ent ever since the openin" of MDH& so#eti#es even ! passin" the Health Ministr . This rendered the #ana"e#ent of the hospital as ineffectual accessories. If the hospital is to function to an accepta!le level of efficienc & efficient #ana"e#ent& with full authorit to decide on the structure and processes of the hospital& 5within the political o!%ectives of the "overn#ent and the #inistr 6& without an interference fro# outside #ust !e installed.

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John Dalli

Johns %o69ins Re6ort 2011

In Au"ust 21//& Johns Hop)ins was co##issioned to anal se the situation at Mater Dei Hospital and to #a)e reco##endations for reor"anisin" its process for a #ore efficient& cost effective service. This report was updated with #inor a#end#ents and resu!#itted on the 2th June 21/2. Anne( / shows the e(ecutive su##ar of the report& which has a detailed anal sis of the processes at Mater Dei and which #a)es reco##endations !ased on the international standards and !ench#ar)s which are a "iven in hospitals of repute. This report cost the Malta *overn#ent around A /.3 #illion and althou"h it is not infalli!le& it does contain #assive insi"hts into the operations at Mater Dei and what are the actions to !e ta)en to i#prove the outco#es in the areas of patient safet & "overnance& clinical practices& hu#an resources deplo #ent and a "eneral up"rade of the i#a"e of the hospital. It does not see# that a proper follow up was #ade on this report& althou"h the #ana"e#ent of Mater Dei Hospital tried to address so#e issues on which the could e(ercise so#e control. Anne( 2 shows the actions ta)en on the report& and the areas which have not !een addressed at all. I !elieve that this report is a ver "ood !ase for the discussions of a root and !ranch refor# of the practices at the hospital so that the Maltese citiBen is "iven a patient centric 3ualit health care e(perience of e(cellence.

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Report on Mater Dei

John Dalli

Finance
The financial s ste# is tanta#ount to !ein" non e(istent. At Mater Dei& there is a one entr !oo))eepin" s ste#& which is not covered ! an accountin" policies that should !e the !asis on which financial transactions are to !e recorded. There are no proper !oo)s of account& no proper records of a#ounts that are due or owin" to the hospital& no control of pa #ents that are #ade& and no #ana"e#ent accounts that could assist #ana"e#ent in ta)in" proper decisions. :o proper fi(ed asset re"isters are )ept and inventor is not controlled at all. All these are #ulti #illion euro assets. The accounts for 21/2 have !een reconstructed over the past two #onths and financial accounts have !een co#piled. Anne( 3 shows the 21/2 accounts and hi"hli"hts fro# the #ana"e#ent letter showin" the deficiencies encountered. +ollowin" is a s nthesis of the o!servations, !orporate "overnance o :o effective control to #ana"e a#ountin" to A231#

earl

hospital operatin" costs

Revenue o :o strate"ic plans to sustain free health care services o Revenue contracts not !illed to service clients !reditors o :o proper #ana"e#ent of earl contractual o!li"ations a#ountin" to A24#. o $ossi!ilit of dou!le pa #ents to creditors o :o control that a#ounts re3uested confor# to co##it#ents #harmaceutical and Medical $upplies o :o proper stoc) control over phar#aceuticals and #edical supplies o :o ph sical stoc) ta)es carried out on phar#aceutical and #edical supplies o C(cessive hi"h value #edical supplies purchased ! consultants o :o control over consu#ption of phar#aceuticals 5A/2#6 and #edical supplies 5A21#6 leadin" to waste and Dout9of9stoc)E situations #ayroll o Fearl overti#e and allowances a#ount to A3@# o Inefficient authoriBation and no controls over pa #ent of overti#e o Sa#e pa rates for Don callE and Don dut E services ! doctors o :o proper Dcloc) in and outE of consultants& doctors and nurses o ?nta)en Gacation Heave and Ti#e 0ff allowances a#ount to A3.1@# o :o #ana"e#ent control over pa roll costs a#ountin" to A/14#.

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John Dalli

%ngineering o Identical spare parts purchased with different unit pricin" o -ivil wor)s authoriBed not in line with approved tender specifications o $a #ents effected to service providers e(ceed contract value o :o e(penditure control in this sector 9 -urrent s ste# leads to a!use &i'ed Assets o ?nauthoriBed transfers of hi"h value #edical e3uip#ent fro# one location to another. o :o proper securit to prevent theft of hi"h value e3uip#ent o +inancial records disclose #edical e3uip#ent at A//1# a"ainst inventor records of A;@# o :o effective control over purchases of fi(ed assets. o +ree = !elow #ar)et leasin" of #edical e3uip#ent to private hospitals and clinics

A costin" e(ercise of the activities at Mater Dei has !een re launched after it had !een discontinued for no valid reason in 21/1. This should provide the !asis for cost control of the processes at the hospital& as well as "ive a proper indication of the char"es that should !e #ade to those who are not entitled to free hospital care at the hospital. The accountin" depart#ent is to !e totall reor"anised and retrained. $roper accountin" policies& in accordance to international accountin" standards are to !e set up& proper control s ste#s are to !e put in place and ti#el & #eanin"ful #ana"e#ent accounts are to !e #ade availa!le to #ana"e#ent to !e a!le to #ana"e the hospital in a cost effective #anner& ensurin" that accounta!ilit is enforced.

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nfor8ation Technolo7:
The Infor#ation Technolo" at Mater Dei is in total disarra . There is no inte"rated s ste#& no holistic approach to a s ste# solution& with the "overn#ent infrastructure of MITA inhi!itin" a co#prehensive approach to sensi!le IT develop#ent throu"h dictated policies& introvert attitudes& heav 9handed !ureaucrac & o!sessive control& and a one trac) approach in procure#ent. This resulted in s ste#s that are totall outdated& services that are o!viousl over priced& total reliance on suppliers for the sli"htest service re3uire#ent 9 !ein" at their #erc even in accessin" patient data 9 a restricted nu#!er of suppliers& and an inefficient s ste# of develop#ent. This is e(e#plified in, A tender for the suppl of IT support to a nu#!er of operatin" s ste# and which was in the ad%udication process for #ore than 2 ears was a!orted. The price of around 24 #illion euros was !ein" 3uoted and the s ste# was not considered to have !een properl defined. The Ministr was infor#ed in April 21/3 that the patient data!ase at the Health Ministr & )nown as $AS will !e discontinued ! the end of the ear as it was such an old s ste# that it will no lon"er !e supported ! the supplier. This "ave little ti#e to see) different s ste#s and was presentin" the Ministr with the onl alternative to roll over the contract with the sa#e supplier at a cost of around A2.4 #illion for a new licence an up"rade and a #aintenance a"ree#ent for a Dte#porar E period of 4 ears. The review tea# i##ediatel started to redesi"n and pro"ra##e& in9house& a new #odern s ste# with increased functionalit . This is now !ein" finalised and should !e i#ple#ented in ti#e ! the end of the ear. Su!stantial hurdles were placed in the wa of the develop#ent tea# fro# various 3uarters& includin" the suppliers who see# to have !een pro#ised a continuation of their contract. It is interestin" to note that so#e da s a"o the Ministr was infor#ed that the licence of the s ste# would not e(pire after all and onl the #aintenance a"ree#ent would need to !e renewed. This new s ste# will include new functionalit includin" the trac)in" of each patient at Accident and C#er"enc and at outpatient clinics& to set accepta!le waitin" ti#es that would help the clinical practitioners to #ana"e patient flow& ensure transparent 3ueuin" dependin" on tria"in"& and suppl #ana"e#ent with an i#portant tool to assess and #onitor perfor#ance. The e(istin" IT s ste#s will !e reviewed to ensure a total inte"ration of all s ste#s within the Health Service& and new s ste#s will !e developed to assist #ana"e#ent and the clinicians to perfor# #ore efficientl . In the process& we will also !e developin" in house IT capa!ilit so that we would not have to rel on e(pensive consultancies and servicin" for the sli"htest re3uire#ent& and would ensure a fir# attitude to cost effectiveness. //

Report on Mater Dei

John Dalli

Human Resources
The #ost i#portant resources at the hospital are its hu#an resources. Althou"h we !oast of the 3ualit of our hu#an resources& their deplo #ent is horrendous. It is safe to state that the hospital is run on the whi#s and convenience of sin"le e#plo ees. Data provided ! the Salaries section of MDH shows the followin", $resentl at MDH there are '34 different shift patterns 5e(cludin" the clinical staff6. The shift patterns are distri!uted a#on" 3242 staff& #ainl nurses More than half of the shifts are assi"ned to a "roup of ten e#plo ees or less while /@ shifts are wor)ed ! a "roup of 41 wor)ers or #ore. MDH has /43 staff that have individual shift The shift patterns "enerate 22 different wor)in" hours=wee). There are 1/4 staff that are on reduced wor)in" hours. This "roup account for 1*2 shifts patterns. There are #an wor)ers who have the sa#e duties !ut different shift patterns and different shift pattern in different sections at MDH.

This #eans that the tas) of pa roll calculation !eco#es a ver la!orious and tric) tas) 521 e#plo ees are re3uired to calculate the pa roll #anuall 6& a lot of disruptions are e(perienced in the flow of wor) and overti#e is "enerated to fill the "aps created ! these distortions. +or e(a#ple& it is a fre3uent occurrence that operations are not started on ti#e !ecause the full tea# does not report to wor) at the sa#e ti#e& and the rest of the tea# has to wait for the last #e#!er to appear. 'orst still& it also happens that nurses chan"e durin" an operation !ecause of roster li#itations. Apart fro# "ross inefficienc & this can also affect patient safet . 0ver the ears& la ers of infle(i!ilit have !een overlaid one on top of the other with the conse3uence of lon"er process ti#es and wasteful hu#an resources. This is the reason wh althou"h& as one can see fro# the Johns Hop)ins report& the staffin" levels at the hospital are ade3uate when co#pared with international !ench#ar)& there is the insistence that we have a chronic shorta"e. Another issue is the inordinate nu#!er of 3ualified clinical staff that have !een #oved out of their area of co#petence to ad#inistrative duties. This #ust !e addressed throu"h an o!%ective and thorou"h Hu#an Resource Assess#ent within an internationall accepted %o! descriptions for each function and international wor) load !ench#ar)s

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Mana"e#ent has& over the ears& !een further wea)ened ! interference fro# political #asters who dictated the appoint#ent of people without an consideration of #eritocrac & forced staff #ove#ents not necessaril on an as needed !asis and who pushed pet va"aries such as fa#il friendl #easures which& thou"h lauda!le in the#selves& were ta)en to e(tre#es with the a!surd results of # riads of un#ana"ea!le roasters. The ?nions have filled the vacuu# created ! a wea) #ana"e#ent. There is the culture of constant co#plaints ! Da""rievedE #e#!ers that lead to constant !ic)erin" !etween union and #ana"e#ent . and the resultant waste of ti#e as there as no set s ste# on how "rievances should !e handled 9 and innu#era!le directives which continue to clo" the wor) flow of the hospital and so#eti#e effect patient safet . Apart fro# this& union leaders see# to thin) that the should !e runnin" the hospital instead of #ana"e#ent. It is i#portant that all those who wor) at the hospital realise that the wor) within and for an or"anisation& and in the sa#e wa as happens all over Malta . and the rest of the world . the #ust wor) within the para#eters set ! the or"anisation and accordin" to the e(i"encies of service. Also& each e#plo ee #ust utilise all his capa!ilities in the !est interest of the patient. Anne( 2 shows the overti#e and allowances paid within Mater Dei hospital. The practices are not accepta!le. There is no real accounta!ilit of who approves overti#e and allowances& no indication that overti#e is wor)ed and allowances are "ranted for a proper reason. 0verti#e is often an incentive used ! #ana"e#ent to "et so#ethin" done. Massive savin"s can !e achieved in this area if #ana"e#ent e(ercises proper control.

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n;entor:
Inventor & within this caption& refers to phar#aceutical and #edical supplies. At the end of 21/2& Mater Dei carried A4.2 #illion in phar#aceutical and #edical supplies inventor . This is a theoretical !oo) value as no stoc) ta)e has !een done in Mater Dei as should !e the practice in a properl ad#inistered environ#ent. Steps are !ein" ta)en now to start a continuous stoc) ta)e s ste# which would "ive a first cut indication of the accurac of the theoretical inventor shown on the records. Durin" 21/2& Mater Dei consu#ed A23 #illion in phar#aceutical and #edical supplies. This consu#ption is #ade without even the !asic controls and in a free9for9 all environ#ent. This #ust account for the waste of #illions of Curos in pilfera"e& outdated stoc)s& and consu#ption of ite#s at hi"her prices then appropriate& )roc<re8ent The -entral $urchasin" Suppl ?nit 5-$S?6 which is the centralised purchasin" and control entit for the Ministr of Health "enerates orders for phar#aceuticals !ased on usa"e& and #ana"es these inventories within stoc)roo#s at *IMan"ia& Madliena and Marsa. There is also a stoc)roo# within Mater Dei. However& there are other su! stores in Mater Dei which are outside the re#it of -$S? such as stoc) in the Main $har#ac and in all the wards. There e(ist in all these stores #an #onths worth of stoc). Cver !od tries to have %ust9in9case inventories so we donIt run out. Fet& we still run out !ut %ust as i#portant& we end up with #an thousands of euros worth of e(pired inventories. This is t pical of inventories within this environ#ent too #uch of what we donIt need and not enou"h of what we want. There are #an ar"u#ents supportin" this chaotic and wasteful environ#ent. The current s ste# fails to inte"rate in one holistic platfor# the de#and for "oods with accurate stoc) records and stoc) infor#ation and with the a!ilit "iven to each entit to see and in3uire what is availa!le where. Instead& we find that -$S? uses a totall different s ste# fro# those at Mater Dei and these two s ste#s do not co##unicate with each other. Cven the codes which should !e a uni3ue reference to an ite# within the s ste# are different fro# each. Therefore we find ourselves with three entities usin" the sa#e co##on dru" identified with a different code and #ana"ed on three different s ste#s. :o wonder we have co#placenc and #alaise. This failure is ine(cusa!leJ it isnIt as if thousands of euros havenIt !een spent on s ste#s. 0n the contrar too #an useless s ste#s were !ou"ht& to wor) independentl of each other& !ecause of the fra"#ented approach that e(ists. And there lies our dile##a. Toda & the "eneral pu!lic co#plains of shorta"es of phar#aceuticals and the wor)ers are !la#ed for not orderin" the ri"ht #aterials at the ri"ht ti#e in the correct a#ounts& et these wor)ers are e3uipped with useless and archaic s ste#s. /2

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S ste#s are not the onl issue here. $rocesses are also at fault. The are non e(istent or not ro!ust enou"h with little or no concern for internal controls. However even the pitiful ones in place are not enforced or used. Therefore the consu#ption of "oods is #ade without even the !asic controls and in a free9for9all environ#ent. This #ust account for the waste of #illion of euros in pilfera"e& outdated stoc)& and consu#ption of ite#s at hi"her prices than appropriate. This is clearl an area which has failed the pu!lic in a !i" wa in the past. This is an area where #illions of euros have !een spent wastefull !ut it didnIt have to. This is one of the priorit issues !ein" tac)led at present. )roc<re8ent of Ser;ices 0ne #a%or flaw is that no real cost effectiveness e(ercise is #ade !efore supplies or services are ordered. A case in point is the renewal of a contract for servicin" of a set of e3uip#ent in Mater Dei. Mater Dei had a contract with the ori"inal supplier of the e3uip#ent for the past five ears totallin" over A4 #illion& and were set to roll over the sa#e contract for another five ears with an additional 3K increase per ear. The 3uestions that a proper s ste# would have as)ed would have !een, Is there an other supplier that can deliver the serviceL 'hat is the cost of the e3uip#ent in 3uestion and how does the #aintenance cost relate to the ac3uisition costL Does the e(perience of the past five ears indicate an chan"es in the contract to i#prove the service and "ive #ana"e#ent !etter controlL 'hat was the e(perience of the 3ualit of service delivered ! the supplier with who# the hospital intended to renew the contractL Is there a lo" of the #aintenance activit durin" the past contract period to esta!lish the cost to the supplier in hu#an resource and spare part usa"eL This will indicate the ade3uac of the char"e !ein" as)ed. Is there a reason wh there should !e an auto#atic 3K increase per ear in the #aintenance feeL

It transpired that The e3uip#ent in 3uestion cost so#ethin" over A < #illion which #eans that we were pa in" a #aintenance fee of /2.4K per annu# of the cost of the e3uip#ent. It was assu#ed that no other supplier could deliver the service. :o anal sis for a review of the contract conditions was #ade. :o anal sis of the cost of deliver of the service was #ade. It is i#portant that the process of reviewin" these service contracts should start in ti#e to "ive the opportunit to #ana"e#ent to #a)e a correct process of co#petitive tenderin" and ad%udication. A short lead ti#e to start a conventional tenderin" /4

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procedure is tanta#ount to a!ortin" an atte#pt to "et a !etter deal fro# the one that was !ein" rolled over. :o tender would !e specified& issued& assessed& ad%udicated and awarded in the four #onths re#ainin" until the e(piration of the current contract period. However an effort has now !een #ade ! all concerned to issue a pu!lic tender ! the end of 0cto!er. This illustrates the deficient purchasin" process in other services contracts which a#ount to a!out A23#illion in total 5Anne( 46 The procure#ent s ste# to !e put in place will ascertain that an e(tensive cost !enefit e(ercise will !e carried out on each service that is !ein" outsourced and which will !e #ade well !efore the e(pir of an e(istin" contract to ensure that effective options are availa!le to #ana"e#ent to ta)e the !est& #ost cost effective decision. This will !e supple#ented ! an effective s ste# to ensure continued scrutin . This is another area where su!stantial savin"s can !e #ade. O<t of Stoc9 )har8ace<ticals An out of stoc) situation is never the pro!le#...usuall it is the s #pto#. Shorta"es are t picall the result of incorrect interpretations of patterns of de#and& !ad plannin" and incorrect procure#ent decisions. 'e have alread stated& earlier in this report& the s ste#ic and procedural pro!le#s of the current s ste# as re"ards to the inventor #ana"e#ent of phar#aceuticals and #edical supplies. It is in this venue that we find the root cause of out9of9stoc) #edicines. Inade3uate co#puter s ste#s and processes that donIt #a)e sense and that #a)es it difficult to ensure that #edicines are availa!le to patients without shorta"es. o The wron" al"orith#s are !ein" used in the procure#ent decisions& !asin" orders on historic consu#ption data rather than future consu#ption as indicated ! patients8 entitle#ent details. These details are ver easil calculated as the entitle#ent of each patient is deter#ined and captured. o $oor if not non e(istent co##unication !etween the different entities involved in the procure#ent 5-$S?6 and distri!ution 5$0F-6 of phar#aceuticals. *overn#ent Bureaucrac in the procure#ent and approval process adds to this #alaise. o It is not unheard of that a purchase re3uisition ta)es up to /< #onths to "et approved. o There is no sensitivit to the i#portance of #edicine procure#ent& and the one siBe fits all s ste# defies lo"ic. o The archaic and !lin)ered tenderin" s ste# is also a cause of the stoc) situation. The followin" e(a#ple illustrates this, /;

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John Dalli

A supplier is late in his deliver of an order. An out of stoc) situation is e(pected and a decision is ta)en to issue a tender to purchase a suppl to !rid"e the e(pected "ap. Suppliers are as)ed to 3uote for this ?R*C:T suppl . The late supplier is on the list of the invited suppliers. The late supplier who )nows the prices 3uotes a cheaper price. Bein" the cheapest tender the late supplier is awarded the tender. The ?R*C:T tender is also not delivered. :o action is ta)en 5I would reco##end that such a supplier should !e !lac)listed as his tender offer was a fraudulent one !ein" #ade when he )new that he could not deliver6.

Other Contrib<tin7 Factors There are other factors that& while the are not the pri#e reason for shorta"es of #edicines& the collectivel contri!ute a hi"h dose of i#pact on availa!ilit . Medicines are a heavil re"ulated co##odit . Medicines arrivin" in Malta #ust !e re"istered with the re"ulator "overn#ent a"enc . This is t picall a slow and e(pensive process. Since our #ar)ets are s#all& #an #anufacturers decide not to sell their products in Malta. 0n the other hand& #anufacturers who are alread re"istered in the C? and therefore technicall the can sell their products here& run into a lan"ua"e pro!le#. Maltese laws state that the la!els and instructions leaflets for all #edicines sold in Malta #ust !e in Cn"lish or Maltese. Cr"o& this law e(cludes #edicines fro# !ein" purchased in Ital & $ortu"al& Spain& +rance& *er#an etc. 'e are li#ited to Cn"land and a few other places. Cven the ?SA #ar)et is closed to us if #anufacturers decide not to re"ister their products in our -ountr . This #eans reduced access and hi"her costs. Availa!ilit then !eco#es an issue under these conditions& not to #ention that co#petitiveness !eco#e al#ost not e(istent. Added to this& procure#ent of #edicines are placed with a ver select "roup of a"ent not #anufacturers !ut a"ents located here in Malta. This restricts even further the a!ilit to levera"e co#petitive !ids to "enerate !etter availa!ilit & lower prices& shorter lead9ti#es and !etter ter#s and conditions. Muite often we are faced with sole source conditions. This is not health and #ost definitel ver frustratin" when one considers how #uch suppl e(ists around the world. 'e are wor)in" with the various #inistries and re"ulators involved to counter these issues and i#prove efficienc & cost effectiveness and availa!ilit . 'orld wide shorta"es of raw #aterials& re3uired in the #anufacturin" of certain #edicines& also cause an out of stoc) condition to the $0F- patients. These conditions cause a lot of an"uish and consternation !ecause solvin" these shorta"es !eco#es ver difficult when one considers our ti"ht #ar)ets& our low volu#es and the #an lar"er clients co#petin" for the sa#e #inuscule availa!ilit .

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Report on Mater Dei n;entor: in %os6ital

John Dalli

?sa"e in hospital wards is not properl trac)ed as there is no inventor control s ste# in place. Inventor in wards and in the operatin" theatres are not controlled and the accessi!ilit to the stores area is open to all. This leads to shorta"es of so#e ite#s in so#e areas were the sa#e ite# can !e carried in other areas. It leads to haphaBard orderin" as no consolidation of re3uire#ents is done at an point in Mater Dei. It also leads to waste as e(pir of ite#s is not properl #onitored. As the new $AS s ste# will ensure the identification of each patient throu"h a !ar9 code ta"& all the consu#a!les used wards& in theatre and in other interventions should !e ta""ed and !arcoded so that. There is proper recordin" of all that has !een used on a particular patient fro# the ti#e of ad#ission to dischar"e. This ensures accurate records of consu#ption and cost. Inventor usa"e is properl controlled and accounted for& as it should reconcile with was is ph sicall reduced fro# the stores. A visit to the stores in the sur"ical area is shoc)in". Access is open to ever one& there is no record whatsoever of the inventor carried& and there is no tracea!ilit of an inventor #ove#ent. The !otto# line of this is e(cessive e(penditure due to pilfera"e and waste. In Mater Dei there is a co#plete lac) of !asic lo"istic= securit . C(pensive supplies and e3uip#ent are NstoredN 5if ou can call it that6 in unsecured roo#s with e(cess to ever !od even visitors. There is no active i#plant and instru#ent inventor on the "eneral sur"er side at the #o#ent. Instru#ent sterile collections are #ost of the ti#e unattended with outside doors co##onl left open awaitin" for outside visitor to enter and "od )nows what can happen. :o!od too) the proper initiative to activate the card readers and create a first level securit area. +ro# now on it will !e # responsi!ilit . In short& inventor control is non9e(istent. This has its "enesis not onl in inefficient financial #ana"e#ent& !ut also in the fact that there is no proper stoc) )eepin" function and s ste# in Mater Dei. Action is !ein" ta)en to, Monitor and #aintain proper purchasin" activities and develop strate"ies and new wor)in" practices which will eventuall save on costs. Introduce the stoc) control and inventor pro"ra# throu"hout the whole operatin" theatre co#ple( includin" anaesthesia and endoscop . Activate the door #a"nets. Appoint senior nurses to address specific sur"er specialit leadership which will include stoc) #onitorin" and predicted orders and top up needs. This will /<

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John Dalli

reduce traffic in our secured stores which will in turn reduce pro!a!le pilferin". *et the procure#ent officers in the operatin" theatre so that the will understand the needs and "et hand on e(perience. Appointin" the ri"ht people as product evaluators and eli#inate all potential conflict of interests durin" the evaluation process. support the new s ste# of procurin" sur"ical e3uip#ent !ased on 3 re3uisites , o Mar)et research of the product includin" retail price. o C(pression of interest a#on" local suppliers at a pre9deter#ined price. o $a per use s ste# incorporatin" a clause to cover repairs and replace#ent

It is also i#perative that an effective and efficient stoc) )eepin" s ste# is put in place to cater for, An alert s ste# for 3uantif in" re3uire#ents to order An orderin" s ste# that reduces !ureaucrac and ensures a s#ooth deliver process. A receivin" s ste# that ensures that what is received is what is ordered and that the 3ualit is accepta!le 5e.". the e(pir date has not !een chan"ed6. An inventor control s ste# that would )eep proper stoc) accountin"& ta)in" care of all #ove#ents in and out of the different stores and !etween stores so that #ana"e#ent at the Health Ministr and at the various entities would !e a!le to have a view of the level of inventor of ever ite# at all stores locations. An IT s ste# that would !e user friendl and efficient to #aintain such a s ste# without e(cessive effort. A ph sical stoc) )eepin" function 5e.". a continuous stoc) ta)in" s ste#6 that would #onitor the correctness of the theoretical !alances stoc) )eepin" s ste#. This has to !e set up fro# scratch. &nhancin7 Cost &ffecti;eness in the S<r7ical De6art8ents The followin" are e(a#ples of how proper procedures and efficient inventor #ana"e#ent can result in su!stantial cost savin"s. These are issues raised in onl one of the sur"ical sections of the hospital . the orthopaedic section. There was the practice to loan sur"ical instru#ents to private hospitals at no char"e. A new polic has !een introduced to char"e a rental for the use to cover wear and tear& financin" cost and ad#inistrative costs. $neu#atic driver attach#ents worth A/;2&111 have !een !ou"ht without the attach#ents that #a)e the# usa!le and have sat on the shelves for #onths. Three t pes of #odular Hip replace#ent i#plants are used& that& althou"h havin" the sa#e functionalit and are e3uall accepta!le var in cost fro# />

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A@11 each to A/211. As there is no standard procedure& the sur"eon #a)es his own choice as to which to use. A #aintenance contract for repairs of so#e e3uip#ent was esta!lished at A2&411 each repair. 'hen this was 3uestioned& and a cost was re3uested for a particular repair . e3uivalent to that contracted . the cost was A@41.

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Clinical )ractices
The level of care is hi"h& !ut it is disor"anised. The throu"hput at the hospital and the cost is dependent on the presence of clinicians on site& and a definitive state#ent of procedure that is strictl adhered to. This depends on the function of a -linical Director for the hospital havin" the responsi!ilit to set procedures& #annin" levels and !ench#ar)s for each clinical activit . He should also !e responsi!le to #onitor the clinical activit and preside over 3ualit assurance. Mater Dei Hospital has e(tensive sur"ical capacit which is #anifestl underutilised !ecause of wor)in" arran"e#ents that have !een handed down for# one collective a"ree#ent to the other without an one havin" the sense and the coura"e to correct the#. Cven thou"h a part ti#e=full ti#e #i( should !e #aintained it should !e #ade clear that the core clinical hu#an resource in the hospital #ust !e #ade up of clinicians who are dedicated to the hospital& "ivin" their services solel to the hospital on a full ti#e !asis. This applies in particular to the -hair#an of each -linical Depart#ent who has to have a#ple ti#e to deal with the ad#inistrative duties re3uired of hi# while #aintainin" his clinical output. It is also i#perative that -hair#en should !e "iven ad#inistrative assistance to !e a!le to properl fulfil their ad#inistrative and control function which could also include devolution of !ud"et responsi!ilit . To encoura"e close colla!oration !etween the two #ain providers i.e. doctors and nurses& and to i#prove the wor)in" efficienc of !oth& one #a conte#plate creatin" tea#s of doctors=nurses=para#edical staff to lead and wor) throu"h their wor)load to"ether. Cach Depart#ent could have a nu#!er of such tea#s. The Johns Hop)ins report deals e(tensivel and reco##endations. with these issues in their o!servations

The s ste# !ein" developed will !e !ased on the followin" para#eters. Doctors in the health centres and private practice will !e "iven access to patient clinical infor#ation as level of authorisation per#its& and would !e e(pected to deepen their level of dia"nosis& so that onl patients needin" specialist attention will !e referred to Mater Dei out patient clinics and AOC Referrals to Mater Dei will !e throu"h the "eneral practitioners and throu"h doctors in health clinics. An IT s ste# should !e installed in health clinics and fa#il doctor clinics and will !e used ! the doctors to ensure that all the dia"nostic steps are perfor#ed and all infor#ation a!out the patient is dul co#pleted. This will !e connected in real ti#e to Mater Dei. Cach patient reportin" at Mater Dei will !e i##ediatel ta""ed& "iven an identification with !ar code& chip or #a"netic strip which will !e #onitored at each step of the service "iven to hi# so that waitin" ti#es !etween one step

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and another will !e #onitored and chec)ed a"ainst !ench#ar) ti#es introduced in the s ste#. This will also ensure transparent 3ueuin". The s ste# will also #aintain a record of patients who have !een undul referred to Mater Dei. In "eneral people waitin" to !e served should !e infor#ed of what is happenin" as the lac) of )nowled"e of the e(pected ti#e line is #ore a""ravatin" than the actual ti#e spent waitin". 'aitin" list for outpatient and sur"ical services should !e tac)led ! increasin" the throu"hput at Mater Dei !oth in out patient clinics and in sur"ical theatres. The hu#an resources needed for this should !e !rou"ht on !oard throu"h o A redefinition of the co#ple#ent of staff that should !e involved in each event accordin" to international !ench#ar)s. o A redeplo #ent of hu#an resources to ensure that people are redirected to wor) in their specialities o A redeplo #ent of hu#an resources to ensure that ade3uate resources as esta!lished ! international !ench#ar)s are utilised where the are in fact needed throu"hout the hospital. The waitin" list initiative #ust !e two pron"ed. o The first is to ensure that the Hospital 0peration is perfor#in" at a level that all the de#and is satisfied& therefore not increasin" the waitin" list. This will !e a per#anent arran"e#ent o The second is a one off pro%ect to eli#inate the waitin" list over a predeter#ined ti#e fra#e to !e decided !ased on availa!le financial resources.

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Wa: For=ar>
The or"anisation and deliver of a patient centric 3ualit health care e(perience of e(cellence is not& e(actl & a new paradi"# where success can onl !e reached throu"h trial and error. There is no dou!t that the provision of health care is challen"in", the !alance !etween pu!lic financin" of health and rationin"J the provision of latest phar#aceuticals and dru"s and the i#pact on pu!lic financin"J the provision of health treat#ent to patients at the ti#e when the need it so that their health& and hence their role as parents& e#plo ers or e#plo ees& "randparents does not de"enerate unnecessaril . These and other challen"es !rin" in a level of co#ple(it that are not present in other econo#ic and social sectors and which re3uire special strate"ic& polic and or"anisational solutions. Fet& "ood #odels of !est practice in the or"anisation and deliver of patient centric 3ualit health care e(perience of e(cellence e(ist. 'ith stron"& deter#ined and tenacious political and ad#inistrative leadership and the involve#ent of sta)eholders the i#ple#entation of !est practice deliver of a patient centric 3ualit health care e(perience of e(cellence ! Malta8s health service is realisa!le. There are& however& cornerstone or"anisational and #ana"e#ent principles that deter#ine the level of success realised. These are discussed hereunder. Refoc<sin7 the Role of the Fo<n>ation of (e>ical Ser;ices Despite the role of the central depart#ents within the Ministr of Health and the centralised role assi"ned to the +oundation of Medical Services 5+MS6 the health service hospitals& includin" MDH& operate independentl fro# one another& replicatin" co##on services& appl in" different processes and !ench#ar)s& etc. In order to counter this wasteful fra"#entation it is !ein" reco##ended that the hospital health services ar# of the health sector is desi"ned to replicate a private sector #odel where co##on and shared services are lod"ed in a 7*roup8s holdin" co#pan 8 with the vertical service providers providin" a #ana"ed service deliver throu"h clear service level a"ree#ents. The report& therefore& reco##ends that the role of +MS is refocused fro# one that is 3uasi co#pletel a facilities and pro%ect #ana"e#ent ar# to that of a *roup Holdin" -o#pan providin" a Hospital 0versi"ht +unction operatin" under the supervision of the Ministr of Health. As a Hospital 0versi"ht +unction& +MS would !e assi"ned the followin" responsi!ilities,

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Head a new cross9hospital "overnance structure to #onitor perfor#ance for the provision of acute& reha!ilitation and outpatient patient centric 3ualit service. Be responsi!le for the develop#ent of a 7#ana"e#ent8 infrastructure within +MS and the hospitals for which it is assi"ned responsi!ilit . Be responsi!le for the develop#ent of co##on shared services infrastructure within +MS and across the hospitals for which it is assi"ned responsi!ilit . whether these are I-T& financial& phar#aceutical #ana"e#ent& and other !ac) office functions. Develop centrall a"reed !ench#ar)s at !oth or"anisational level and operational processes !ased on a $atient -harter directed to achieve a patient centric 3ualit service provision. $rovide oversi"ht& sharin" of !est practice and !ench#ar)in" across the acute& reha!ilitation and outpatient health service value chain. 'or) with all participants to ensure that the centric 3ualit service provider. are a 7!est9in9class8 patient

Achie;in7 ?"est3in3Class@ )atient Centric A<alit: Ser;ices )ro;i>er The refocusin" of +MS into a Hospital 0versi"ht +unction does not #ean that hospitals will !e #ana"ed centrall . This is an approach that this report does not su!scri!e to. The #ana"e#ent approach to hospitals will !e one that is !ased on output and outco#e !ased plannin" fra#ewor) that would achieve the followin", Ri"orous anal sis of intended results cascaded down fro# #acro9level i#pacts& such as increased e#plo #ent& to specific sector outco#es& such as increased acute interventions. These results would !e clearl defined within the respective hospital8s !usiness and financial plan& with indicators and tar"ets& and with relevant #onitorin" and evaluation #easures. Additionall & output and outco#e9!ased !ud"etin" would ensure that a hospital8s !usiness and financial plan !ud"et is for#ulated to deliver the results specified in plannin". Hin) to "enerational !ud"etin" in order to ensure that the outco#es and outputs to !e achieved are ali"ned with the plannin" ti#e horiBon set within the respective health sector polic "oals. Hin) to the resources& structures& processes& etc. re3uired to i#ple#ent the polic o!%ectives with the effectiveness& efficienc & and econo# in deliverin" the intended activities and services.

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This will translate in a $erfor#ance A"ree#ent !etween each individual hospital and the +MS. The principle !ehind the introduction of a perfor#ance fra#ewor) was one of instillin" an ethos of #ana"e#ent accounta!ilit . 'ithin the para#eters of a perfor#ance fra#ewor)& #ana"e#ent is "iven the fle(i!ilit to operate its !usiness provided that it #ana"es and #eets the )e perfor#ance criteria set in advance and a"reed upon with central "overn#ent there! appl in" the principle of e#power#ent and fle(i!ilit in line with specific accounta!ilit . The inclusion of this polic o!%ective to !alance #ana"e#ent and operational fle(i!ilit with a perfor#ance for accounta!ilit fra#ewor) will create a hospital #ana"e#ent environ#ent that !alances central and e( ante controls with the level of perfor#ance and accounta!ilit fra#ewor)s introduced within each individual hospital . which would include the, 0r"anisational culture and perfor#ance focus of the entit . Develop#ent of tar"ets for all strate"ic indicators. $rocesses underpinnin" strate"ic plannin" and priorit settin" includin", o The lin)s !etween plannin" and !ud"etin" or resource allocation. o The lin)s !etween plannin"& !ud"etin" and #ana"e#ent c cles. o -lear ali"n#ent with "overn#ent plans. $rocesses for #easurin" and reportin" "overn#ent perfor#ance. $rocesses and structures for evaluatin" perfor#ance . includin" the relevant accounta!ilit structures to ensure perfor#ance s ste#s deliver #eanin"ful results.

The introduction of a perfor#ance for accounta!ilit fra#ewor) would !e !ased on a )e perfor#ance #ana"e#ent #ethodolo" such as the Balanced Scorecard. 'ithin the a#!it of a corporate perfor#ance fra#ewor) the role of the +MS would include, Drivin" the i#ple#entation of the new perfor#ance and accounta!l fra#ewor). 'or)in" colla!orativel with hospitals to strea#line and stren"then e(istin" #easure#ents and reportin" re3uire#ents that #eet the principles of the new fra#ewor). Monitorin" the overall perfor#ance of the hospitals a"ainst a"reed criteria. Identif in" potential perfor#ance issues or suspect activities. Intervenin" as and where appropriate.

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Appl in" sanctions where a!use is identified includin" the withdrawal of the #ana"e#ent accounta!ilit provided under the ter#s of the perfor#ance a"ree#ent.

A perfor#ance accounta!ilit fra#ewor) is a )e lin) of the oversi"ht #ana"e#ent chain set with re"ard to the devolution of #ana"e#ent authorit to line #ana"e#ent. This is so !ecause a perfor#ance for accounta!ilit fra#ewor) entered into !etween +MS and a hospital would provide& in tande# with the hospital8s !usiness and financial plan& the #ana"e#ent accounta!ilit para#eters that the head of a hospital is to operate within as well as the a"reed strate"ic and )e perfor#ance tar"ets the incu#!ent is to #eet. Moreover& the on9"oin" #onitorin" ! +MS ena!led ! this oversi"ht #ana"e#ent fra#ewor) would allow it to intervene& and if necessar suspend the devolved #ana"e#ent authorit & as and when necessar . De;elo68ent of a ?(ana7e8ent@ nfrastr<ct<re An erroneous polic applied so far is that whilst *overn#ent was willin" to invest in 7hard8 infrastructure . whether this was MDH itself& the hi"h tech infrastructure& etc. . it held !ac) in investin" in the #ost valua!le infrastructure of all, #ana"e#ent and talent. The provision of a patient centric e(cellent 3ualit e(perience& undou!tedl & re3uires e(cellent health facilities and technolo" . C(cellent health facilities and technolo" & however& do not translate in a patient centric e(cellent 3ualit e(perience. The 7heart and #ind8 of a hospital are s)illed& co#petent people . and the a!ilit to #ana"e a co#ple( arra of resources . dru"s& !eds& hi"h tech health technolo" & clinical and #ana"e#ent infor#ation& etc. Malta has li#ited& if at all& e(pertise in hospital #ana"e#ent. In developin" the #ana"e#ent infrastructure *overn#ent #ust !e coura"eous in headhuntin" and !rin"in" to Malta e(patriate e(pertise in hospital #ana"e#ent until such ti#e that Malta develops the hu#an capital talent. It is pertinent to underline that Malta has in the past ta)en such an approach such as& for e(a#ple& in the #anufacturin"& touris#& I-T and financial services sectors, which toda are driven 3uasi totall ! Maltese talent. In tande# with such an approach it is i#portant that the *overn#ent esta!lishes a partnership with a leadin" universit of international repute to tea# up with the Ministr of Health and the ?niversit of Malta to develop Maltese hu#an capital in hospital #ana"e#ent. The develop#ent of e(pertise in the Hospital Mana"e#ent area will therefore !e three pron"ed, ?se of +orei"n e(pertise to run Mater Dei Hospital for a "iven period of ti#e. Durin" this period local candidates are to !e sent a!road to train and "ain e(perience.

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At the sa#e ti#e a Hospital Mana"e#ent -ourses=Trainin" $ro"ra##es are to !e set up locall .

&;ol;in7 %os6ital Ser;ice Deli;er: into a %i7h 0al<e A>>e> !e= &cono8ic Sector The transfor#ation of Malta8s acute& reha!ilitation and outpatient services deliver chain #ust !e driven ! the prero"ative of assurin" an econo#ic& efficient and effective health sector that delivers a patient centric 3ualit health care e(perience of e(cellence to the Maltese citiBen. :evertheless& this report underlines& stron"l & that the vision for transfor#ation of Malta8s acuteJ reha!ilitation and outpatient services deliver chain should !e far !older. The develop#ent of a new econo#ic sector !ased on hospital service deliver is one of hi"h value added to Malta8s econo# . and e(perience in overseas %urisdictions shows that this is also intrinsicall lin)ed to 5health6 touris#. Adoptin" an approach where Malta lin)s with a hospital of international repute with re"ard to securin" assistance in the transfor#ation that needs to !e underta)en& assistance in hi"h 3ualit hospital #ana"e#ent& and assistance in developin" Maltese hu#an capital in hi"h 3ualit hospital #ana"e#ent would constitute a se#inal step forward to the develop#ent of such a new econo#ic sector. If the wa forward presented in this report is e#!raced& *overn#ent should tas) the Ministr of Health and a newl re9focused +MS to wor) with sta)eholders to develop and i#ple#ent the strate"ic inte"rated fra#ewor) that will successfull i"nite such a sector si#ilarl to what has !een achieved in I-T and +inancial Services.

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John Dalli

Rethin9in7 Wellness 2 The F<t<re of %ealthcare 1

In the past ears I have !een insistin" that health deliver should shift towards wellness. The o!%ective& I insisted over and over a"ain& is to )eep people out of hospital !eds. This is the onl wa in which we ensure that when people need to !e in a hospital& the will still find the !est of care which is totall accessi!le. A 6ara>i78 chan7e A"in" and technolo" are drivin" the future of healthcare deliver which has to !e different fro# the s ste# that we are usin" toda . 'e still have a healthcare deliver s ste# in which ph sicians see patients for /1921 #inutes and decide what to do !ased on what the doctor learned in #edical school or pic)ed up throu"h continuin" #edical education. 'e still have hospitals and nursin" ho#es and ph sicians offices or"aniBed in #uch the sa#e wa the were 41 ears a"o. True& there are lots of new technolo"ies that allow hospital sta s to !e shorter and to turn patients livin" roo#s into I-?s& !ut the institutions reall haven8t chan"ed #uch. 'ill the co#!ination of new science on the one hand and a"in"& de#andin" consu#ers on the other !e si#pl !olted on to the current chassis of healthcare financin" and deliver L Most healthcare e(perts !elieve this does not co#pute. 'e desperatel need to innovate. the "reatest innovation #ust co#e in the deliver of #edical care. Healthcare needs to !e redesi"ned to full ta)e advanta"e of advances in infor#ation technolo" . The #edicine of the future needs to !e hi"h tech and hi"h touch& it needs to co#!ine the potential efficienc of e9co##erce with co#passion and carin" fro# #otivated professionals. nno;ation (nnovation has quic)ly come to be one of the top issues that senior healthcare e'ecutives and medical professionals are thin)ing about. There is a realiBation that there is an ur"ent need to challen"e the ver philosophies upon which the s ste# is !uilt. The result is that #an health care leaders are see)in" insi"ht into
/

C(cerpts fro# contri!utions fro# the followin" we! sites, Three Arup Specialists Share Their Gision of The +uture of Healthcare Desi"n 9 htt6455===.arch>ail:.co8543/./.5 Hoo)in" Ahead, A +uturistIs Giew of Healthcare . Ian Morris 9 http,==ian#orrison.co#=loo)in"9 ahead9a9futurists9view9of9healthcare= Healthcare 2111 . The transfor#ative trends that will reall define our future . Ji# -arroll 9 http,==www.%i#carroll.co#=21/1=/1=healthcare921219the9transfor#ative9trends9that9will9reall 9 define9our9future=P.?#oM?Ql#i#2

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the #a%or scientific& technolo"ical& consu#er and social trends that will allow for so#e ver dra#atic chan"e in the concept of health care deliver . $reventative concepts are part of this !i" transition. 'ithin a decade& health s ste#s would have successfull transitioned fro# one which Dfi(es people after the 8re sic)E to one of preventative& dia"nostic "eno#ic9!ased #edicine that treats patients for the conditions we )now the are li)el to develop. Innovation is no lon"er %ust a fashiona!le phrase Rwith the co#in" chan"es& innovation is the critical new leadership focus for e(ecutives in the health care sector. 'hat is happenin" is this, we are in the #idst of a lon" ter# trend in which Dpreventative #edical careE will co#e to e(ceed what we spend on Dreactive #edical care.E $reventative care ta)es #an for#s& fro# "enetic testin" 5to deter#ine what conditions people are li)el to develop in their lifeti#e6 to wellness and other preventative pro"ra#s. Si#pl put& let8s fi( people !efore the are sic)& rather than treatin" the# after the 8ve developed a condition. In the future& an effective Health Deliver s ste# will !e, )re;entati;e4 'ithin the ne(t decade& if we do the ri"ht thin"s& we will have successfull transitioned the s ste# fro# one which Dfi(es people after the 8re sic)E to one of preventative& dia"nostic "eno#ic9!ased #edicine. Treatin" patients for the conditions we )now the are li)el to develop& and re9architectin" the s ste# around that realit . 0irt<al B Co88<nit:4 A s ste# which will provide for virtual care throu"h !io9 connectivit & and e(tension of the hospital into a co##unit 9care oriented structure. 'ireless and #o!ilit health apps that lin) consu#er wellness #onitorin" to #edical professionals. Cons<8er >ri;en4 A consu#er driven health care environ#ent for non9critical care treat#ent that provides si"nificant opportunities for cost reduction. Real ti8e4 Real ti#e anal tics and location9intelli"ence capa!ilities which provide for co##unit 9wide #onitorin" of e#er"in" health care challen"es. DJust9in9ti#eE )nowled"e concepts which will help to deal with a profession in which the volu#e of )nowled"e dou!les ever si( ears.

That and #uch& #uch #ore. The fact is& we are "oin" to witness #ore chan"e in the world of health care in the ne(t ten ears than we have seen in the last 211. In the last few decades& rapid advances in !oth #edical and consu#er technolo"ies have created revolutionar possi!ilities for ever aspect of healthcare& fro# prevention to dia"nosis to treat#ent and !e ond. +ro# D:A9!ased preventative care to di"ital 2>

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appoint#ents with doctors thousands of #iles awa & the future holds enor#ous potential for i#provin" lon"evit and 3ualit of life for people around the world. Such innovation will re3uire real leadership fro# polic #a)ers& entrepreneurs& and ph sicians ali)e. The sta)es are hi"h. If we don8t innovate it could "et u"l .

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A S8art Sol<tion
The opti#al approach to tac)lin" a root and !ranch refor# in the health s ste#& for the !enefit of the Maltese $opulation& is a !i partisan approach. All political parties in the countr have a conver"ent health polic & pro#isin" free health care for all for ever. However #ore and #ore& an political "roupin" that will find itself in power will !e findin" it #ore and #ore difficult to honour this lauda!le co##it#ent. The refor#s necessar in the wor) ethic& fle(i!ilit and patient focus& as well as the discipline which has to !e discovered in the health s ste#& re3uire a co#pact polic and political front that can withstand the onslau"ht of vested interest levera"in" political !lac)#ail. 'e have #ana"ed to have a !i partisan approach in #a%or pro%ects li)e the financial services sector and the rent refor#. Both were success stories& The Health s ste# is #uch #ore i#portant than an of the a!ove sectors& and the political leaders #ust find the coura"e to %oin forces and deliver a health s ste# that "ives a #uch !etter social return than at present.

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A %ealth Ser;ices &cono8ic Sector

Malta has the ele#ents that can propel it into a hu! of Medical Services in the Mediterranean Re"ion and !e ond. An or"anised& well #ana"ed& efficient& patient centric hospital s ste# can attract patients fro# countries where 3ualit is inferior to ours 5e.". Hi! a6 and fro# countries where costs are #uch hi"her to ours 5e.". ?SA6 This will, Be a contri!utor to the Maltese Ccono# & +unds the local health s ste# to i#prove sustaina!ilit -reate #ore e#plo #ent& $resent an opportunit to our professional classes to i#prove their inco#e& *ive a !roader !ase for invest#ent in hi"her technolo" in the #edical sector Increase the scope of $rivate 0perators in the Medical Sector& I#prove the service "iven to the local population.

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John Dalli

(ater Dei %os6ital S:ste8s Re;ie= B !ee>s Assess8ent

JO%!S %O)- !S (&D C !& !T&R!AT O!A#

Final Re6ort 3 &Cec<ti;e S<88ar:

(arch 1*1 2012

A7en>a
Reco##endations 0ptions Movin" +orward +ive Fear Develop#ent $lan Re3uired *overn#ent Support

Reco88en>ations
Assess8ent Foc<s4 &i7ht Wor9 Strea8s
1. Ali"n#ent of 0r"aniBational and Mana"e#ent Structures with Strate"ic 0!%ectives 2. Hospital 0perations& -linical Mualit and Safet S ste#sJ and Service9 Deliver $ro"ra#s . $erfor#ance of the -linical& :ursin" and Allied Health -are $rofessionals Inte"ration of Infor#ation Technolo" S ste#s 5. 0pportunities for Hin)a"es to Advance -linical and Research -olla!oration -urrent Hu#an Resource -apacit and +uture 'or)force :eeds Accidents O C#er"encies Depart#ent $erioperative Services 5Sur"ical 'ait Hists6 Alignment of Organisational and Management Structures with Strategic Objectives

4. 6. 7. 8. 1.

Develop Mission and Gision State#ent for MDH that is inte"rated into the overall national strate" for the countr Is health care s ste# 0utline )e strate"ic o!%ectives& such as, Cli#inate outpatient and inpatient waitin" lists Csta!lish transparenc & accounta!ilit and autono# Develop safe and hi"h93ualit #edical care and #easure perfor#ance a"ainst international !est9practice !ench#ar)s Cnsure effective and sustaina!le hospital operations& #easured ! international industr standards

.
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John Dalli

Heavil increase s ste#s support staff in all areas. The current level of #ana"e#ent and ad#inistrative staff is ne"li"i!le as co#pared to what a hospital needs to have to operate !asic s ste#s that support clinical care and hospital operations. Csta!lish #edical and nursin" leadership structures& e.". co##ittees. Assi"n sufficient autono# "overnin" !oard to hospital leadership with clear accounta!ilit to a

Mana"e and !loc) the ne"ative i#pact of unions on #ana"e#ent decisions& that currentl continuousl restrict i#prove#ents in hospital #ana"e#ent and patient care 2. Hospital Operations, Clinical ualit! and Safet! S!stems" and Service# $eliver! %rograms

Csta!lish clinical and operational policies and procedures !ased on *oint !ommission (nternational

*++,-./0*0/12 30*2.*,.3.

D-4-516 78*5/09 *338,*2+6*0/-20 3*:-09 65*23. D-4-516 30,*0-;/+ 65*2 =*2*;-=-20> /2+58./2;

*2. <-.

:1,

Accidents O C#er"encies perfor#ance i#prove#ent 0peratin" theatres perfor#ance i#prove#ent Reha!ilitation O *eriatric pro"ra#s develop#ent Involve all healthcare providers in plannin" and i#ple#entation

-reate infrastructure develop#ent plans. . %erformance of the Clinical, &ursing and Allied Health Care %rofessionals

Csta!lish philosoph for practice in nursin" co##unit & redefine the role of -hief :urse 0fficer and develop standards that "overn clinical care and nursesI wor) Develop strate"ic plan and transition fro# centraliBed to unit9!ased #ana"e#ent. Replace outdated nursin" protocols 9 even a"ainst union resistance 9and create 3ualit i#prove#ent pro"ra#s with nurse cha#pions& for e(a#ple in #edication #ana"e#ent Develop continuin" education pro"ra#s for nurses and care wor)ers 4. 'ntegration of 'nformation (echnolog! S!stems 32

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John Dalli

Csta!lish IT C(ecutive -o##ittee O ?ser *roups led ! clinicians to levera"e IT invest#ent and address the followin" areas, -linical transactions O docu#entation Hon"itudinal health #aintenance record Intensive care clinical s ste#s -linical decision support Measure and #onitor the perfor#ance of health care deliver s ste# Identif and trac) clinical 3ualit and operational )e perfor#ance indicators 5S$Is6 Assess the 3ualit and usefulness of clinical and operational data Develop dedicated IT support staff for Mater Dei Hospital 5. Opportunities for )in*ages to Advance Clinical and +esearch Collaboration

Csta!lish a central office and re"istr of !io#edical research !etween Mater Dei Hospital& ?niversit of Malta and the Ministr to #a(i#iBe sharin" and colla!oration Develop a for#aliBed intellectual propert polic !etween MDH and BioMalta Maintain a clear patent process for all parties Identif and define opportunities for student participation in the research Disse#inate !est practices and research at re"ular intervals a#on" healthcare providers to #a(i#iBe the use of resources and foster colla!oration and learnin" Institute $oint90f9-are 5$0-6 testin" nation9wide and allow researchers to have access to data C(plore s ner"ies and research colla!oration opportunities !etween Mater Dei and Johns Hop)ins& particularl in "enetics& dia!etes& neuroscience& cardiolo" & i#a"in" and patient safet . 6. Current Human +esource Capacit! and ,uture -or*force &eeds

-o#pletel redesi"n the recruit#ent and selection process to allow effective& efficient

+5/2/+*5 2--.3 *2. 210 12 5-2;0?9 <8,-*8+,*0/+ 615/+/-3 *3 /3 21@. I0 0*A-3 @-55 14-, * 9-*, 01 ,-65*+- ,-0/,-.> 1, ,-3/;2-. 6,1:-33/12*53 82.-, 0?and ti#el ac3uisition of wor) force !ased first on 34

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John Dalli

+8,,-20 C*6*+/09 B8/5./2; EB-,+/3- CCBED 6,1+-33 T?- *<3-2+- /3 +14-,-. <9 +13059 14-,0/=E30*<5/3? ?/;?"5-4-5> -B-+80/4,15- ,-6,-3-20/2; 0?- ?136/0*5 01@*,.3 82/123 P,-4-20 82/123 <51+A/2; +,/0/+*5 30*::/2; *2. 3+?-.85/2; .-+/3/123 *2. 3-,/18359 /=6*+0 6*0/-20 3*:-09 *2. +5/2/+*5 78*5/09 1: +*,E30*<5/3? 6*0/-20 *2. +*,2--.3 *3 ?/;?-30 6,/1,/0/-3 /2 30*::/2; .-+/3/123 C123/.-, *2. =*2*;- 5-;*5 *+0/123 *;*/230 82/123> @?-,-4-, 2-+-33*,9

Revisit ph sician and nurse staffin" needs& schedules and #onitorin" s ste#s. Develop professional and e(perienced HR tea# to #ana"e nursin" needs& disciplinar actions& industrial relations& recruit#ent process. Develop and #andate trainin" pro"ra#s in leadership and #ana"e#ent. Ali"n HR policies and procedures with J-I standards. 7. Accidents . /mergencies $epartment 0A./1

Adopt appropriate AOC #etrics as institutional priorities. 3;

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John Dalli

Reallocate current space to allow for additional AOC treat#ent spacesJ inpatients should !e relocated outside of the AOC. Review the inpatient ad#ission process& includin" decision #a)in" points and rin" fenced !eds. ?tiliBe !est practice for inpatient !ed #ana"e#ent includin" central !ed control and esta!lish a priorit for patients ad#itted throu"h the AOC. Review and revise current AOC tria"e process and revise the Nfront endN AOC operations to #atch patient de#and. Develop evidence9!ased clinical practice "uidelines and care protocols. Review the slow and erratic inpatient dischar"e process& focusin" on non9acute& Nlon"9sta N patients and the real !ottlenec) outside of the Mater Dei Hospital $atients held in corridors represents a serious safet ris) Assess elderl care and reha!ilitation capacit !uildin" options outside of Mater Dei Hospital 8. %erioperative Services 0Surgical -ait )ists1

Csta!lish standards and rules as part of an advanced schedulin" and #onitorin" s ste#. C#power operations #ana"ers to i#prove utiliBation and throu"hput. Re9evaluate nurse staffin" needs in operatin" roo#s 50R6 and esta!lish ad#inistrative s ste# to support 0R procure#ent& suppl & inventor & case preparation #ana"e#ent. Develop s ste# to #easure cost per sur"ical case. IncentiviBe sur"eons to wor) #ore hours and fill entire 0R capacit . O6tions (o;in7 For=ar> &arl: Achie;e8ents So#e specific reco##endations have alread !een i#ple#ented ! leadership with positive effects, C#plo ed -00 and Medical Director Identified 0perational 0!%ectives for 21/2 Appointed a nurse as 0R Mana"er Redefined the hospitalIs Mission State#ent Set up a S ste#s Review Board to loo) at patient safet issues Defined an 0perations $lan for :ursin" Started coordination with BioMalta the e(ecutive

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Report on Mater Dei Be"un definin" AOC protocols

John Dalli

)rereD<isites to S<ccess However& professional staff& i#proved infrastructure and certain decision #a)in" autono# will !e re3uired to i#ple#ent )e strate"ic reco##endations, Sufficient ad#inistrative support will !e re3uired to #ana"e recruit#ent and selection process& data and infor#ation collection& and dail operations Ma%or chan"es in nurse staffin" will !e necessar in order to #ana"e clinical care and cha#pion 3ualit and safet pro"ra#s Si"nificant efficienc i#prove#ents of procure#ent and hirin" processes are prere3uisites to successful perfor#ance i#prove#ents within the hospital -e: Ris9s If status 3uo is #aintained& the followin" are the #a%or hi"h9ris) events in the ne(t /2922 #onths, E ?nion actions with ne"ative i#pact on patient safet & 3ualit of care and operational perfor#ance E $atient safet !reaches& such as the recent Sle!siella out!rea) E Hospital !eds and the Accidents and C#er"encies Depart#ent overflow in the event of a patient sur"e Fi;e3$ear De;elo68ent )lan I (ain +oals 1. Csta!lish "overnance structures 5hospital "overnin" !oard& !alance of accounta!ilit and autono# 6 2. Identif e(ecutive tea# 5ph sician& nurse& operations& hu#an resources and infor#ation technolo" 6 . Recruit and retrain ad#inistrative staff to support leadership and operations 4. Reor"aniBe nurse staffin" s ste# to #a(i#iBe staff utiliBation 5. Develop and i#ple#ent strate"ic plans for, E Mualit assurance and patient safet s ste#s E Bed #ana"e#ent E 'aitin" list #ana"e#ent E :ursin" wor)force develop#ent E Inte"ration of infor#ation s ste#s E Hospital infrastructure develop#ent E Joint -o##ission International accreditation )ossible Johns %o69ins S<66ort /. Dele"ate nurse and hu#an resources e(ecutives for a li#ited initial ti#e period with the #ain o!%ectives of E Developin" leadership structures and recruitin" staff E -reatin" strate"ic plan and startin" i#ple#entation E $reparin" Maltese candidate for ta)in" over role 2. Train new operations e(ecutive and #id9level hospital ad#inistrators 3<

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John Dalli

3. Train selected ph sicians and nurse leaders 2. $rovide on9"oin" consultin" support to hospital leadership in strate"ic areas E Mualit assurance and patient safet s ste#s E Bed #ana"e#ent E Inte"ration of infor#ation s ste#s Joint -o##ission International accreditation ReD<ire> +o;ern8ent S<66ort H 1. Strea#line hu#an resources recruit#ent and selection process E +ast trac) Mater Dei Hospital positions within current s ste# E Assi"n process cha#pion fro# $ri#e MinisterIs 0ffice Miti"ate ne"ative i#pact of health care union actions on patient safet and clinical 3ualit E Dele"ate union ne"otiations and decisions to hospital leadership E Support the hospital in challen"in" unions throu"h le"al actions

2.

3. Cnsure ti#el develop#ent and inte"ration of infor#ation s ste#s E Cna!le hospital leadership to #ana"e the selection and i#ple#entation of new s ste#s E Assi"n dedicated IT support staff to the hospital.

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Annex 2

OFF C& OF T%& C% &F &I&CUT 0&

In" Joseph -aruana& -hief C(ecutive 0fficer Tel, 5T34;6 2424 2/1/ +a(, 5T34;6 2424 2/12 C9#ail, %oseph.o.caruanaU"ov.#t

Res<8e of J% Re6ort
Tas9 EiF 3 Re;ie= the Ali7n8ent of Or7anisational an> (ana7e8ent Str<ct<res =ithin (ater Dei %os6italGs strate7ic obHecti;es E This was left in the hands of the previous per#anent secretar to decide on a wa forward in its i#ple#entation as it ta)es awa a si"nificant level of control that is currentl within the Ministr and not within MDH Mana"e#entIs control toda E I set up a senior e(ecutive tea# to "ive us a first se#!lance of "overnance E I #eet ever ear with all #ana"ers and directors 5a!out 41 e#plo ees6 where we review vision and #ission and identif strate"ic o!%ectives that we then tac)le ever ear Tas9 EiiF 3 &;al<ate %os6ital =i>e o6erations incl<>in7 clinical D<alit: an> safet: s:ste8s an> ser;ice >eli;er: 6ro7ra88es E *ave the relevant parts of the report to the nursin" and doctor #ana"e#ent tea#s for their i#ple#entation where possi!le E Dis#antled co##ittees which were a Ital)in" shopI and started /4 action tea#s& with e(ecutive powers& to tac)le )e hospital issues so#e of which arisin" fro# this part of the report. These tea#s are still underta)in" action tas)s toda E Identified the phar#aceutical practices as e(tre#el outdated. Started audits of wards and a ward top up service as well as clinical phar#acists with wards. :ot all wards are covered ! this service due to lac) of phar#acists at MDH. & this dispensin" and audit process is currentl onl happenin" in 2/ out of 32 wards. Before JHI we did not have this s ste# at all. Tas9 EiiiF 3 &;al<ate the 6erfor8ance of the clinical1 n<rsin7 an> allie> health care 6rofessionals

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E *ave the relevant parts of the report to the nursin"& doctor and allied care professionals #ana"e#ent tea#s for their i#ple#entation where possi!le E Received "ood feed!ac) fro# nursin" tea# !ut ne"li"i!le feed!ac) fro# doctors or allied professions 2 J all wor) done ! nursin" on the report is docu#ented E Started the concept of patient safet & reor"anised incident reportin" s ste#& launched a dedicated tea# for Mualit and Safet for the whole hospital that is currentl focusin" on The ri"ht Bed for the Ri"ht $atient 9 leadin" to safe and 3ualit care. E As)ed to have a full ti#e person focusin" on the detailed i#ple#entation of tas)s 5ii6 and 5iii6 and approval received fro# $er# Sec to appoint Dr. Senneth *rech on the tas) i#ple#entation. Tas9 Ei;F 3 Assess the nte7ration of T s:ste8s V Csta!lished what we )new alread that MDH has no authorit for an IT activit as it is all controlled ! MITA and the Ministr for Health. E This part of the report sa s #ore a!out what should !e done than a!out what we have as we have ver little so far fro# an MDH position. Tas9 E;F 3 &;al<ate o66ort<nities for lin9a7es bet=een John %o69ins (e>icine an> (ater Dei hos6ital to a>;ance clinical an> research collaboration E :o wor) was done on this for# and MDH standpoint Tas9 E;iF 3 Assess the c<rrent h<8an reso<rce ca6acit: at (D% an> i>entif: 9e: actions necessar: to 8eet f<t<re =or9force nee>s E :o action was ta)en as a result of this part of the report other than identif in" where we have #issin" hu#an resources fro# a nurse to patient ratio in the different depart#ents. HR is totall controlled ! the Ministr of Health and MDH cannot hire or fire. Tas9 E;iiF 3 1 Con><ct a co86rehensi;e s:ste8s re;ie= an> nee>s assess8ent of the acci>ent an> e8er7enc: EAB&F >e6art8ent E Csta!lished that the Area allocated for AOC is s#allJ currentl in the process of to creatin" space in the ad#ission areas to "ive AOC #ore area where to see their patients E -linical protocols are now put in and perfor#ance #easures and tar"ets esta!lished a"ainst which we can !ench#ar) + Tas9 E;iiiF 3 Con><ct a co86rehensi;e assess8ent of 6re3o6erati;e ser;ices Eo6eratin7 theatresF

T?- @1,A <9 FHI ./. 210 *..,-33 *55/-. 6,1:-33/123 /2 *29 5-4-5 1: .-0*/5 *2. :1+83-. =*/259 12 28,3/2; *2. 01 * 5-33-, -B0-20 12 .1+01,3.
3

T1 <- @1,A/2; 12+- 0?- 2-@ IOT 3930-= /3 /2 65*+-

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V Review spea)s a!out how practices can !e #ore efficient& na#el in the #ana"e#ent of the theatres& the shifts of nurses to !e #ore effective and the IT support to #onitor perfor#ance o I as)ed for a theatre director in Jul 21// !ut this one has not !een appointed et o :urses shifts will need a tussle with the union to ta)e up and this was not seen as
the ri"ht thin" to do %ust !efore the elections when I raised the issue over a ear and a half a"o o MITA and our own Ministr D* IT stopped #e fro# outsourcin" to an local co#petent supplier the writin" of software for #e to #ana"e theatre efficienc !etter.

The JHI report instilled the notion and discussion and focus on all aspects of $atient Safet & which I a# told& previous to this JHI visit& was not considered at an wide scale in the hospital. Jose6h Car<ana Chief &Cec<ti;e Officer (ater Dei %os6ital + rd $eptember ,-.+

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John Dalli Annex 3

(ater Dei %os6ital Finance De6art8ent Obser;ations an> Reco88en>ations

A detailed report of this C(ecutive Su##ar has alread !een presented and discussed with the Minister of Health,

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John Dalli

(AT&R D& %OS) TA# State#ent of +inancial $osition

3/ Dece#!er 21/2

Restated 2012 J ASS&TS !on C<rrent Assets $ropert & plant and e3uip#ent 0ncolo" pro%ect 41.11331'// 3 2012 J 21// A

Restated 21// A

33;&1;2&3@2 <3<&;>1

41.11331'//

33;&>13&1;2

C<rrent Assets Stoc) 0peratin" and other receiva!les -ash and !an) '12231*4* 2111'1./, *0412/0 4&41/&1</ ;&22<&423 <3@&124

,1/431.33

/2&@;;&;2>

Total Assets

42*10,,1432

32>&;;>&@/3

&AU T$ A!D # A" # T &S Ca6ital an> Reser;es *overn#ent C3uit *overn#ent recurrent allocation -urrent operatin" costs 1,21.,41*,* E22.13*314*/F *10133013'* /@>&<<3&<>2 522@&23<&>//6 ;/1&331&34;

E''14..1,/3F Accu#ulated depreciation E1''1,,'14*/F 3//10**10/3

52@&444&1/@6 523@&4/4&//@6 324&2;1&222

C<rrent #iabilities 0peratin" creditors and accruals -apital creditors 2*10*/14*' /411.,4 22&21>&2>/ 9

2,1011133/

22&21>&2>/

Total &D<it: an> #iabilities

42*10,,1432

32>&;;>&@/3

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John Dalli

(AT&R D& %OS) TA# State#ent of -o#prehensive Inco#e

2 +or the ear ended 3/ Dece#!er 21/2

2012 J

21// A

Re;en<e

112121/*2

/&;42&3;<

O6eratin7 Costs Direct e(penditure Indirect e(penditure E1,31.1.1*,,F E341'20102.F 5/@>&/@;&@<26 5//&<42&2;<6

E20.133.1,0'F

5/>/&12>&1426

!et O6eratin7 Costs Ad#inistration costs

E20,112'1,43F E21123,1,2,F

5/<>&3@2&;<26 53<&1;2&22@6

!et Deficit for the :ear

E22.13*314,0F

522>&1>3&2@>6

24

Report on Mater Dei

John Dalli

(AT&R D& %OS) TA# $a roll Su##ar ! -ost -entre J

Annex 2

Cost Centres

"asic

Allo=ances

O;erti8e

De><ctions

+ross

Total

Sur"er and su! Spec K Medicine K * naecolo" and 0!st K Medical $aediatrics K 0rthopaedics K -ardiac Services K 0phthal#olo" K Anaesthesia K Accident O C#er"enc K Dental K Medical I#a"in" K $atholo" K Infection -ontrol K $s chiatr -are K Ancillar Services K A#!ulance Transport K Bio#edical Cn"ineerin" K Ad#inistration K -SSD K -leanin" K Da -are K

4&/43&2>@ 100 @&2;2&24< 100 2&>2;&322 100 3&2;<&3@1 100 /&@32&//@ 100 3&2;<&114 100 >22&212 100 2&23<&43/ 100 3&1>4&>4; 100 /&/>/&//@ 100 3&4<2&<;2 100 2&2>>&;@2 100 /<1&></ 100 /2&/2/ 100 /&>22&1/3 100 3@1&122 100 <><&;>; 100 4&<2;&<44 100 2<2&>;; 100 213&132 100 42;&;2< 100

2&/4@&3>2 .1 2&<1@&>;/ *4 2&3>;&<44 4/ 2&/@;&2/> *3 /&242&/21 .4 /&>/;&1;3 '' ;2@&;</ */ 3&2@2&1;1 ,. 2&;>/&>/2 ., 2@1&322 23 /&@<>&1;2 '0 /&>31&;@2 43 ><&@3< '' @@1 * 24;&2@2 23 21;&<3> '* 2>1&4<3 32 /&;@<&<42 2/ /2<&32< 31 ;@&>@4 33 />1&;2; 3*

2;4&/;2 ' 21;&3;; ' @;&1;/ 2 /12&2;< 3 @1&2@4 4 2@2&243 14 22&;<< 3 3/;&@@; , /2/&2>< ' 2&222 0 /1;&</2 3 2@/&><2 * 2&>@2 2 9 3 />&<@2 1 //>&13; 32 4@&32> * <4;&;<1 1' /14&22/ 22 />&2@> / 22&41; 4

<3&<22 2 //@&224 2 @4&/;> 2 2@&>4/ 1 2>&14/ 2 43&24; 2 //&@/2 1 ;<&312 2 22&/41 1 2&2@> 0 2@&24; 1 2;&12/ 1 /&2/4 1 ;< 1 /2&12/ 1 /1&<13 3 2&@22 0 22&>2/ 1 3&>/> 1 /&2>1 1 22&334 '

>&2>2&132 1.4 /2&44>&/21 1*. @&322&1@/ 14/ 4&;>>&/1; 1*4 3&22@&2;1 1.* 4&<12&<;4 1*, /&;13&14> 1,0 <&/4>&1;3 1.4 4&<<4&1/< 1/0 /&24>&;2/ 123 4&243&2<2 1'2 ;&;@;&2<4 14. 2</&2@> 1'' /2&<23 10* 2&21<&33< 124 ;<4&1>2 1.' /&223&<;2 13. <&3/>&2;> 143 @32&<3; 1'2 2<<&>>; 142 @/4&222 13*

2><&2<3 10 @/>&>24 10 2<2&<33 10 32;&221 / /;1&>;1 / 321&/3/ 10 <@&343 / 2/2&2@2 / 3/1&@/4 10 //4&>12 10 342&/<2 10 23;&1<1 10 /;&;1/ / /&2@2 12 211&@>3 10 3<&/2; 10 >/&/<1 10 4>1&21@ 10 2>&1>< 10 21&<22 10 43&<>/ 10

>&>>1&4/4 1/4 /3&2@>&1;4 1,. @&<1;&>12 1'. ;&124&324 1,4 3&3<<&221 1/* ;&/22&>>; 1,, /&;>1&2/2 1,/ <&4@3&43; 1/3 ;&/>4&@33 200 /&4@4&423 132 4&<14&;;@ 1*2 @&//2&3;4 1'. 2>@&<<1 1*' /2&3/@ 11. 2&;1>&/3/ 134 @23&221 1/' /&334&122 14/ <&>1>&;@4 1'3 @</&>32 1*2 31>&<21 1'3 @;>&33; 14*

2;

Report on Mater Dei

John Dalli

Cost Centres

"asic

Allo=ances

O;erti8e

De><ctions

+ross

Total

DoctorsI Muarters K 0peratin" Theatres K $har#ac K 0utpatients K :ursin" Relievin" $ool K Cn"ineerin" K ?nallocated $a roll K

/14&/3/ 100 /&;;1&4@3 100 <@>&/1/ 100 <3&@;3 100 /&2>@&><< 100 /&1<4&4@@ 100 @/;&>24 133

34&4</ 34 @4>&>;@ 4* 2//&;>3 24 /;&21< 20 44/&;2/ 42 332&;;2 31 23<&22/ 44

/1&;3@ 10 /3;&;4< . 3;&;1; 4 9 3 /1>&222 . /1<&@@4 10 //&433 5 0 0

>>

/4/&241 144 2&4/3&12< 1'1 /&/22&<2> 12.

/1&@<2 10 /@/&1/1 10 <;&<@< 10 @&>@< 10 /3@&>;2 11 //1&</3 10 ;>&;<2 13

/;2&132 1'4 2&;<2&14> 1*2 /&21>&@1@ 13. /1<&1<@ 12/ 2&1;>&@31 1'/ /&;33&144 1'0 /&12<&3;4 124

22&/2> 3 2&4@/ 1 ;2

/11&/1> 120 /&>3/&@;@ 14/ /&422&222 140 >4<&;<3 142

2@&1<; 2 2&@@4 0 @&>>; 1

Total Total K

*0123,1303 100

321//'1/2* ''

31.,21/'. *

,,*1./0 1

/*132/12/. 1*0

'1/021*1* 10

10212311/14 1,0

2@

Report on Mater Dei

John Dalli

(AT&R D& %OS) TA# 21/2 -ontractual 0!li"ations

Annex 6 A

)ai> Contractor *2 Securit Services $ar)sec Hi#ited Malta Healthcare -aterers Mualit -aterin" and Retail ServiBBi Malta Hi#ited Sols CHSupport Services Hi#ited 'asteserv Malta Hi#ited A"enBi%a Appo"" Al!erta Me))ani)a :B Cn"ineerin" Schindler Services Hi#ited Te)traco Titan International GR- Teleco# Details Reception and "uardin" services Securit and par)in" services $atient #eals Staff #eals -leanin" Haundr Handscapin" #aintenance -are wor)ers 'aste disposal Rechar"e pa roll +ire e3uip#ent& detection and doors BMS #aintenance Hifts certification Hifts #aintenance Medical "ases -hillers #aintenance $ABW 0al<e 2&33;&<@1 ;;;&<42 2&313&//< ;43&<2@ 4&;;1&/11 2&3;1&4<2 >3&;12 3&@22&@>< /24&@<; /;<&242 @/<&1<4 2&11@&4>2 /3&321 />@&22@ 3/1&/12 /1>&;24 /3&34/ 23&2</&33<

Contract 0al<e 2&2;3&/</ ;>4&2// 2&33>&<24 4//&<33 4&111&111 2&311&111 >2&@<> 3&411&111 Difference 5/2;&3//6 52<&44@6 53;&@1@6 /2/&>>2 ;;1&/11 ;1&4<2 </4 222&@>< /24&@<; /;<&242 @>;&<;; >1/&>12 /4&2/3 /</&4/4 2</&<12 ><&/@< 5@<&@</6 /&/14&;>2 5/&<@36 /4&@/2 2<&311 //&2;@ /3&34/ 2/&/@<&4/4 2&312&<23

C(cludin" #aintenance contracts on Medical C3uip#ent which a#ounts to a!out A2 #illion per annu#.

2<