Improving Effectiveness in Health Care Service Delivery

Improving Effectiveness in Health Care Service Delivery New Zealand David Dean, PhD General Manager, The Health Roundtable Institute of Public Administration Australia Hobart, 4 November 2005 1 Key messages • • Australia has excellent health outcomes However, the health system is under intense and growing pressure Hospitals are at the epicentre of this pressure • • Maintaining our excellent outcomes will require – Accountable organisations – Effective leaders • Peer-to-peer benchmarking assists hospital leaders find innovative solutions 2 Some Background David Dean – PhD in Social Science in 1978 – Ten years as management consultant with Booz-Allen Hamilton – Led hospital improvement projects in Australia in early 1990’s – Set up own consulting business in 1993 – Australian citizenship in 1995 The Health Roundtable – Founded in 1995 by Bill Kricker and John Youngman – Non-profit membership organisation open to major public hospital chief executives – Shares operational problems and innovations at hospital level – Started with 7 members in 1995 – Has grown to 34 members in 2005 – about 1/3rd of all public hospital inpatients – General Manager of The Health Roundtable since 1995 3 Background… The Health Roundtable … An Innovation Clearinghouse • Health care from hospital perspective Operational focus Share problems Share innovations No role in public policy setting No direct government funding Provide CEO information network Health Roundtable • • • • • • UHC IHI 4 Background… 34 Organisational Members – over 50 Hospital facilities “FOUNDING” CHAPTER Royal Perth Hospital Royal Adelaide Hospital Melbourne Health Bayside Health, Victoria John Hunter Hospital Princess Alexandra Hospital Royal Brisbane & Women’s Hospital Counties Manukau District Health Board (Auckland) Canterbury District Health Board (Christchurch) Eastern Health, Victoria “ALL STARS” CHAPTER Sir Charles Gairdner Hospital Flinders Medical Centre Barwon Health, Victoria Austin Health Royal Hobart Hospital Westmead Hospital St George Hospital Townsville District Health Service Capital & Coast District Health Board (Wellington) Fremantle Hospital The Queen Elizabeth Hospital Waitemata DHB, NZ “OLYMPIAN” CHAPTER Royal Darwin Hospital Southern Health, Victoria St Vincent’s Melbourne The Canberra Hospital Prince of Wales Hospital St Vincent’s Sydney Gold Coast Hospital Auckland District Health Board Health Waikato, Hamilton Mater Health, Brisbane Lyell McEwin Hospital, SA Plus: Regional Health Improvement Network 5 Outcomes Australia’s health care system has delivered excellent outcomes … 6 Outcomes Low & declining infant mortality Infant Mortality Rates 1994 & 2000 (per Thousand) Infant mortality rate 1994 9.0 8.0 7.0 6.0 Per Thousand 5.9 6.2 6.7 6.2 7.9 Infant mortality rate 2000 7.1 6.1 5.2 5.3 5.0 4.0 3.0 2.0 1.0 - 5.8 Australia Canada New Zealand Country UK USA 7 Outcomes High & improving life expectancy Life Expectancy at Birth - 1994 & 2000 Male Life Expectancy 2000 Male Life Expectancy 1994 84 82.1 82 80 78 Years Female Life Expectancy 2000 Female Life Expectancy 1994 81.5 80 81.0 79 79.9 79 79.5 79 81 76.6 75 76.0 76 74 73 72 70 68 66 75.9 74.8 74 73 73.9 72 Australia Source: Australia's Health 2004, Table S12 Canada New Zealand Country UK USA 8 Outcomes Lower standardised mortality rate Age-Standardised Mortality Rates 1999 (All Causes) - per 100,000 population Male 700 600 511 Deaths per 100,000 Female 547 567 597 500 400 465 474 375 304 329 249 393 407 300 200 100 0 Japan (1999) Australia (1999) Canada (1998) New Zealand (1999) United Kingdom (1999) USA (1999) 9 Source: Australia's Health 2004, Table S18 Country and Year Outcomes Health Costs 20% Higher than UK - Half of USA Australian Health Costs Relative to UK and USA (In $A - GDP Purchasing power conversion) 180% 160% 140% 120% Percent 100% 80% 60% 40% 20% 0% Compared to UK Compared to USA Source: Australia’s Health 2000, 2004 19 85 19 86 19 87 19 88 19 89 19 90 19 91 19 92 19 93 19 94 19 95 19 96 19 97 19 98 19 99 20 00 20 01 Year 10 Outcomes A Good Health Care Report! 11 But – can we maintain these outcomes? 12 Pressures Ageing of the population Source: Productivity Commission, 1999 13 Pressures Global consumer access to information - aortic aneurysm example 26,600 pages 2001 2005 1,040,000 pages 14 Pressures New (expensive) treatments 15 Pressures Dramatic rise in drug expenses Australian Pharmaceutical Expenses (Constant Prices) Billions $12,000 $10,000 Real Growth at 9.4% per year (After inflation) $8,000 $6,000 $4,000 $2,000 Australia’s Health 2004. Table S49: Total recurrent expenditure on health, constant prices(a), 1991–92 to 2001–02 ($ million) $- 1991–92 1992–93 1993–94 1994–95 1995–96 1996–97 1997–98 1998–99 1999–00 2000–01 2001–02(b) 2002-03 16 Pressures Health Costs growing 6.9% pa - much faster than the economy as a whole Australian Health Expenditure (Billions) $120,000 $100,000 $80,000 $ Billions Approaching $80 Billion Growing over 6% per year $110+ Billion by 2010 $60,000 $40,000 $20,000 $1960 1965 1970 1975 1980 1985 Year 1990 1995 2000 2005 2010 17 Source: AIHW,National health expenditure, current prices, 1960-61 to 2000-01 Pressures Health care now costs $4,000 per person Australian Annual Health Cost Per Person $5,500 $5,000 $4,500 $4,000 $3,500 $3,000 $2,500 $2,000 $1,500 $1,000 $500 $1994 1995 1996 Cost per person now about $4,000 Dollars 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Year Source:, Australia’s Health 2000,2004 18 2010 Pressures Ageing Workforce US example Source: http://bhpr.hrsa.gov/healthworkforce/reports/rnproject/report.htm 19 Pressures Global competition for health workers USA alone – short 500,000 nurses http://bhpr.hrsa.gov/healthworkforce/reports/rnproject/report.htm#chart1 20 Key messages • • • • • Australia has excellent health outcomes However, the health system is under intense and growing pressure Hospitals are at the epicentre of this pressure Maintaining our excellent outcomes will require – Accountable organisations – Effective leaders Peer-to-peer benchmarking assists hospital leaders find innovative solutions 21 Hospital Epicentre These pressures are focused most acutely on hospitals Funding Squeeze Knowledge Explosion Hospitals Staffing Rigidity Ageing Population 22 Hospital Epicentre Pressures on the Health System Hospitals Ageing Population 23 Hospital Epicentre Expecting 25% growth in elderly (80+) this decade to 3.9% of population Australian Population by Age Group 100% 90% 28.7 21.2 20.3 18.3 Under 15 15-64 65 to 79 80 and over 80% 70% 60% 50% 66.7 67.3 67.7 40% 30% 20% 10% 0% 63 6.8 1.5 9.4 2.7 9.3 3.1 10.1 3.9 25% increase in decade to 2011 1971 1997 2001 2011 24 Source: ABS. Demography, 1961; Population by Age and Sex, Australian States and Territories, June 1992 to June 1997 (Cat. no. 3201.0); Population Projections, 1997 to 2051 (Cat. no. 3222.0). Hospital Epicentre Over 80s already 11% of all Patients Distribution of Patients by Age Group - 1996/97 to 2002/03 19 Member Hospitals with continuous data 100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 9.1% 11.3% 0-14 15-54 55-69 70-79 80 and Over 1997 2000 2001 2002 2003 25 Hospital Epicentre . . . and 22% of all emergency beddays Distribution of Emergency BedDays by Age Group - 1996/97 to 2002/03 19 Member Hospitals with continuous data - Acute Care Type, Excluding Dialysis 100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 22.2% 20.8% 0-14 15-54 55-69 70-79 80 and Over 1997 2000 2001 2002 2003 26 Hospital Epicentre Elderly use 8 times as many bed days as younger people Hospital Bed Days per year per Head of Population - 2001 6.0 5.5 5.0 Average Bed Days per Year 4.0 3.0 About 8 times higher than the rest of the population 2.4 2.0 1.0 0.8 0.3 0.6 0.7 0.0 0-14 15-64 65-79 Age Group 80+ Overall Source: AIHW Table 7.5 2001/2002, Australian Bureau of Statistics Overall excluding Elderly 27 Hospital Epicentre Pressures on the Health System Knowledge Explosion Hospitals 28 Hospital Epicentre Robotic Surgery http://www.cts.usc.edu/rsi-davincisystem.html 29 Hospital Epicentre New Knowledge and Technologies • • • • • • • • Genomics Proteomics Metabolomics Molecular Imaging Nanotechnology Bioinformatics Molecular Therapeutics Molecular Imaging National Cancer Institute 30 Hospital Epicentre Pressures on the Health System Funding Squeeze Hospitals 31 Hospital Epicentre Public Hospital funding share continues to decline – now below 35% Components of Recurrent Health Expenditure 100% 90% 80% 70% Percentage Community Health Pharmaceuticals Med Services Nursing Homes Private Hospitals Public Hospitals 1974- 1984- 1988- 1992- 1996- 1999- 2000- 2001- 200275 85 89 93 97 2000 01 02 03 Year 32 60% 50% 40% 30% 20% 10% 0% Source: AIHW:http://www.aihw.gov.au/publications/hwe/hea01-02/hea01-02_tables-040225.xls Hospital Epicentre Little new overnight bed capacity added to the system in a decade Total Public and Private Overnight Separations and Patient Days by Year (in Thousands) 21,000 20,000 19,000 18,000 17,000 16,000 15,000 14,000 13,000 12,000 11,000 10,000 9,000 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 19,327 19,973 Bed Days 0.3% growth per year 2,912 Separations: 0.6% growth per year 1993-94 1994-95 1995-96 1996–97 1997–98 1998–99 1999–00 2000–01 2001-02 3,076 2002-03 33 Source: AIHW Hospital Statistics, Table 2.3 Hospital Epicentre Most growth has been in same-day admissions … Total Hospital Inpatient Episodes 1993 to 2003 in '000 (with annual growth rate) PublicO'Nite 7000 PrivateO'Nites Public SameDay PrivateSameDays Overall Growth 3.7% per year 6000 +10.7% Episodes (Thousands) 5000 4000 +5.9% 3000 +2.8% 2000 1000 -0.4% 0 1993/94 1995/96 1997/98 1999/2000 2001/02 2002/03 34 Two Year Intervals Hospital Epicentre … while public hospital bed nights have dropped almost 1% per year Total Hospital Inpatient BedDays 1993 to 2003 in '000 (with annual growth rate) PublicBedNites 25000 PrivateBedNites 20000 Bed Days (Thousands) +2.0% 15000 10000 -0.9% 5000 0 1993/94 1995/96 1997/98 1999/2000 2001/02 2002/03 35 Two Year Intervals Hospital Epicentre Increases in Emergency medical patients have led to reductions in Elective surgical patients Change in Types of Bed Occupancy 19 Member Hospitals (Comparing July-August 1996 and 2004) Change in Emergency Beds Change in Elective Beds Total Bed Change 1000 Emergency up 600 beds Difference in Occupied Beds 2004 to 1996 500 0 -500 -1000 Elective down 760 beds -1500 July Wk1Mon July Wk2Mon July Wk3Mon July Wk4Mon Ju-Au Wk 5Mon Aug Wk 6Mon Date Aug Wk 7Mon Aug Wk 8Mon Source: HRT, Bed Occupancy.xls 36 Hospital Epicentre … with Emergency patients occupying over 62% of beds, up from 56% in 1996 Emergency Overnight Occupancy As Percent of Total Occupancy19 Health Roundtable Member Hospitals (July-August 1996 and 2004) 1996 % Emergency 100% 90% 80% 70% 2004 % Emergency 68% 63% 56% 62% 56% 61% Beds Occupied 60% 50% 40% 30% 20% 10% 0% July Wk1Mon Emergency Share of Public Hospital Beds now 7 percentage points higher than in 1996, reducing overnight elective surgical capacity July Wk2Mon July Wk3Mon July Wk4Mon Ju-Au Wk 5Mon Date Aug Wk 6Mon Aug Wk 7Mon Aug Wk 8Mon Source: HRT, Bed Occupancy.xls 37 VOLUME PREDICTIONS Predicting the Future is Tricky! 38 Predictions Predictions from 1991 predicted 28% fewer bed days than actually used in 2001 National Health Strategy (1991) -Hospital Predictions for 2001 Predicted for 2001 25 19.8 Actual 2000-2001 20 19.4 15.13 19.35 15 -5% 10 6.1 5 4.2 3.6 3.7 +28% +45% 0 Australian Population (Million) Hospital Separations (Million) Bed Days (Million) +3% ALOS (Days) 39 Predictions An additional 1.8 million bed nights (5,000 beds) will be needed by 2011 • Due to elderly growth + population growth at current levels of hospital usage Extra Beds Needed @ 365 day occupancy 53 1,791 428 2,598 BedNight Age Population Bed Nights Bed Nights Population Bed Nights Change Grouping 2001 ('000) 2003 ('000) per Person 2011 ('000) 2011 ('000) '000 0-14 3,981 1,297 0.33 4,041 1,317 20 15-69 13,999 9,810 0.70 14,932 10,464 654 70-79 1,162 3,925 3.38 1,208 4,081 156 80+ 644 4,756 7.39 772 5,704 948 Total 19,785 19,788 1.00 20,953 21,566 1,778 4,871 • ... Creating more strain on public and private hospital systems 40 Source: AIHW, ABS, Chappell Dean analysis – same-day stays excluded from calculations Predictions Alternative is to make dramatic reductions in elderly length of stay • 17% reduction in acute length of stay for elderly Overall 6% reduction needed to keep occupancy at current levels • Extra Beds BedNight Needed @ Or Reduce Age Population Bed Nights Bed Nights Population Bed Nights Change 365 day Average Bed Grouping 2001 ('000) 2003 ('000) per Person 2011 ('000) 2011 ('000) '000 occupancy Nights by 0-14 3,981 1,297 0.33 4,041 1,317 20 53 1% 15-69 70-79 80+ Total 13,999 1,162 644 9,810 3,925 4,756 0.70 3.38 7.39 14,932 1,208 772 10,464 4,081 5,704 654 156 948 1,791 428 2,598 19,785 19,788 1.00 20,953 21,566 1,778 4,871 6% 4% 17% 6% 41 Hospital Epicentre Pressures on the Health System Hospitals Staffing Rigidity 42 Hospital Epicentre Medical Workforce Example All hospitals are experiencing some staffing shortages …related to larger, system-wide problems such as: • Number of places available in Australian medical courses and training programs • Increasing reliance on overseas trained doctors, and • Changes in the work aspirations and expectations of new generations of doctors. THE PUBLIC HOSPITAL MEDICAL WORKFORCE IN AUSTRALIA, AMWAC Report 2004.3 August 2004 43 Hospital Epicentre Nursing Workforce Example • August 2004 – Nursing Workforce Advisory Committee: •“Shortfall of 5,504 nurses in 2006” •“Shortfall of 8,329 nurses in 2012” AHWAC 2004.2 Unprecedented shortages are forecast, but the solutions are “train more of the same” rather than redesign the work 44 Hospital Epicentre “We have met the enemy, and he is us” Pogo, Earth Day 1971 45 Hospital Epicentre Our own worst enemy ... • • • Rigid work demarcations Professional entry barriers “Silos” of expertise • • • Endless paper documentation No “memory” beyond patient discharge Five-day culture for a seven-day problem • • Lack of leadership and direction “Rearrange the deck chairs” solutions 46 Key Principles Every system is perfectly designed to produce the results it gets. (D. Berwick) 47 How to Improve Effectiveness? • • Accountable Organisations Effective Leaders 48 Accountable Organisations required in a rapid change environment • • • Clear Goals Clear Accountability for Results Agreed Resources • • Delegated Responsibility Long-term Vision 49 Accountable Organisations The Detailed Structure of an Organisation   Managers Leaders Supervisors C.E.O.                “Accountability Hierarchy”  E. Jaques          Resource Resource Centre Managers Centre      =    Resource Centre Staff Source: W A Kricker, 2004 50 Accountable organisations Resource Centre Managers THE RESOURCE CENTRE  Resource Centre Leader Sub Products Inputs •Labour •Materials •Depreciation •Overheads Resource Centre People & Processes Outputs •Activity •Cost •Quality •Timeliness' Products Source: W A Kricker, 2004 51 Accountable organisations Resource Centre Building Blocks • • • • • • • Clear accountability Clear task definition Clear output expectation Chief Executive Department / Clinical Stream THE RESOURCE CENTRE Clear output measurement Rapid feedback Single source of funds Clear operational plan Sub Products  Resource Centre Leader Inputs •Labour •Materials •Depreciation •Overheads Resource Centre People & Processes Outputs •Activity •Cost •Quality •Timeliness' Products 52 Accountable organisations Devolution of decision making • • • • • • Complexity and Rapid Change require devolution of decision making Central planning works only in stable, routine environment Optimal working unit size – less than 150 people Highly skilled resource managers are incompatible with central planning Clear accountability for resources and results is essential Health organisations need devolution for competent patient care 53 Sources: E Jaques, W Kricker, M Gladwell Accountable organisations Resource Centre structure allows views from multiple directions Operational Plans (Activity, Expenditure, Finance) can be viewed from several perspectives By Department A Clinical Stream =All Relevant Patient Episodes By Sector Pa tie nt Ep iso de 54 Accountable organisations Long-term Vision & Tenure Required to Manoeuvre the Healthcare Supertanker • Elliott Jaques research in 1970’s and 80’s Major Facility Managers need ability to plan 5-10 years ahead • • Health System Leaders need ability to plan 10-20 years ahead Source: E Jaques, Requisite Organisation, 1989 55 Accountable Health Care Organisations in Australia? • • Clear Goals • • Too many goals Rapid turnover of executives Capped budgets but uncapped expectations Increasing centralisation Clear Accountability for Results Agreed Resources • • • Delegated Responsibility • 56 Clear Goals? We have no shortage of national priorities … Seven national health priority areas (NHPAs): – arthritis and musculoskeletal conditions (osteoarthritis, rheumatoid arthritis, osteoporosis) – asthma – cardiovascular health – cancer (breast, cervix, colorectal, nonHodgkins, non-melanocytic skin, lung, lymphoma, melanoma and prostate) – diabetes mellitus – injury prevention and control – mental health. http://www.nhpac.gov.au/nhpas.htm 57 Clear Goals? … but little translates to the actual health care agreements with States … “1. Eligible persons are to be given the choice to receive, free of charge as public patients, health and emergency services of a kind or kinds that are currently, or were historically, provided by hospitals. 2. Access to such services by public patients free of charge is to be on the basis of clinical need and within a clinically appropriate period. 3. Arrangements are to be in place to ensure equitable access to such services for all eligible persons, regardless of their geographic location.” http://www.health.qld.gov.au/publications/aust_hlth_care_agreement/Queensland.pdf 58 Resources and Responsibility? … “provide free access within clinically appropriate period” … •Who decides? •What goal? •How delivered? •What resources? •Penalty? •Incentive? 59 Resources and Responsibility? States differ in how accountability and responsibility flow to hospitals • • • • • • Victoria – Regional health boards NSW – Area health services Queensland – Zones and Districts WA – Regional health boards SA – Metropolitan regions NZ – District Health Boards Funding mechanisms  Population resource allocations  Casemix funding models  Special grants  Supplemental programs  Activity targets  Incentives & Penalties  Purchaser / Provider 60 Resources and Responsibility? Victoria and New Zealand appear to have more efficient systems Level 1 - By Jurisdiction Clinical Service Group Total All Cases 125% 120% 115% 110% 105% 100% 95% 90% 85% 80% 75% WA Relative Length of Stay Index Current vs Previous Year (Diamond =Current) Casemix Funding + Accountable Boards SA Tas/NT/ACT ALL HRT QLD VIC NSW NZ 61 Leadership is a key issue: Average tenure at the top only 2.5 years Average Senior Executive Tenure of Major Public Hospitals 1995 to 2005 3.0 2.5 2.5 2.0 2.3 2.4 2.5 2.5 Years 1.6 1.5 1.0 0.5 NSW NZ QLD SA VIC WA 62 Source: Health Roundtable membership records, 1995-2005 The Health Roundtable Role • • Explore key issues affecting hospitals Analyse benchmarking data with trusted peers Encourage short-cycle improvement projects Provide peer support • • 63 Benchmarking for Innovations … • • Voluntary comparisons Search for differences – Data Methods – Clinical Practices • Accept “approximate” data No “right or wrong” • • • Opportunity focus Gradual fine-tuning 64 …Not for Accountability to Government • Mandated • • • • • • Uniform Tightly defined Score – “win/lose” Denial “by losers” Gaming the system “Inspectors” needed 65 We use data mining process to find interesting differences • Data aggregated at DRG level for each health service facility At least one facility must be 25% below the benchmark average to qualify for review • • Discuss the data with the lead hospital to identify innovative practices (or data glitch!) 66 Case Study 1: Laparoscopic Cholecystectomy AR-DRG H08 -- Laparoscopic Cholecystectomy Relative Stay Index Comparisons by Facility - Six Months to December 2004 140% 130% Relative Stay Index (100% = 2003/2004 Benchmark) 120% 110% 100% 90% 80% 70% 60% 60% 50% 40% 30% 20% 10% 0% 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 TOT Health Roundtable Member Hospital Facility 67 “Good Practices” Interview of Facility -Same-Day Laparoscopic Cholecystectomy • Screen for patients with “normal” anaesthetic ratings Schedule for morning list Extend day surgery recovery to 7pm Provide discharge meds kit for pain Follow up next day • • • • 68 Case Study 2: Hip Revision or Replacement AR-DRG I03 - Hip Revision or Replacement Overall Relative Stay Index Comparisons by Facility - Six Months to December 2004 160% 150% Relative Stay Index (100% = 2003/2004 Benchmark) 140% 130% 120% 110% 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 TOT 71% 64% Health Roundtable Member Hospital Facility 69 “Good Practices” Interview of Facility Hip Revision or Replacement Pre-surgery Anaesthetic Procedure • • • • Allied health pre-op fitness program Home assessment Epidural + newer agents Medications Mobilisation Rehab Short duration – 45 minutes • Limited range of prostheses • High volume • Limited blood loss -  transfusions • Limited anti-coagulants • Pain control • Within hours – “you will feel better” • At home 70 Knowledge of differences only the first step in diffusion of innovative ideas 1.Knowledge 5. Confirmation 2. Persuasion 4. Implementation Source: Everett Rogers, Diffusion of Innovations, 1995 3. Decision 3. Decision 71 We use Roundtable discussions to share ideas and promote action Lots of comparative data Thought-starter presentations Small group issue teams Ideas to take home 72 The Roundtable Process Other Innovations Spread by The Health Roundtable Patient Safety Efficiency Ageing Population Medical Emergency Teams (MET) Death Audits Day Of Surgery Admissions Relative Stay Index Length of Stay Medical Assessment Planning Units Hospital in the Nursing Home “Frequent Flyer” Programs – Chronic Care Advanced Care Directives Staffing Redesigning Care – Patient Journey Substitution and Extension – Advanced Practitioners Extended Hours – “14/7” 73 Roundtable Success Factors  Voluntary participation by hospital chief executives  Emphasis on practical operational issues  Ownership of process by the members themselves  Face-to-face discussion of real data with peers  Multi-disciplinary involvement of staff  Expect all members to share innovative ideas  Honour Code to prevent harmful use of data  Independent, professional analytical support 74 Key messages • • Australia has excellent health outcomes However, the health system is under intense and growing pressure Hospitals are at the epicentre of this pressure • • Maintaining our excellent outcomes will require – Accountable organisations – Effective leaders • Peer-to-peer benchmarking assists hospital leaders find innovative solutions 75 Thank you! For more information: www.healthroundtable.org.au 76