medical futures

Prof Jennifer Martin is a practising physician and Royal Australian College of Physicians (RACP) board member, AICD NSW council member, and a member of both AICD director professional development and corporate governance committees. Dr Sarah Dalton GAICD is a practising paediatrician and a previous member of the RACP board. She has also held multiple public health executive leadership roles. This article was developed from preparation for AGS 2022.

COVID-19 has forced healthcare organisations to rethink their governance systems and approach to workforce sustainability and to test whether some aspects of performance are still fit for purpose. Governance in healthcare organisations must evolve quickly, so it can implement an updated system that links clinical and corporate governance effectively. Both governance systems can better assess performance and clinical risks through compliance monitoring and regular review of board appointments and risk tolerance.

As a way forward, healthcare organisations could support putting in place governance training programs across leadership roles. This would assist employees understand corporate as well as clinical risk management and the unique role of governance in their organisation. Healthcare boards could regularly listen to stakeholder voices, including those staff on the ground and the communities who use the facilities.

Governance in healthcare is usually assumed to include both corporate governance, that is, managing the organisation’s business performance (including ethics, culture and stakeholder accountability inter alia); and clinical governance, which focuses on improving the quality and safety of patient care.

Clinical governance also focuses on performance in terms of the clinical outcomes of health organisation. It is also a key pillar of corporate governance as business performance also impacts on the clinical governance aspects of patient care, practice processes, staffing quantity and quality, and healthcare flows, such as movement of patients throughout the different parts of the system. Health organisations need to serve the community’s needs and to do so must meet compliance and regulatory obligations.

Health boards therefore have a dual-governance oversight role, with corporate governance activities focusing on regulatory and compliance risks, and clinical governance activities addressing patient safety. An awareness of the linkages and overlap between the two is vital, as is the use of appropriate technology to make that information available to the board.

The health system as a whole regularly has new issues to face. Good governance in the sector thus requires understanding of the complexity and dynamic position of new corporate and clinical governance challenges. Depending on whether the entity is public, private or a mix of both, the dual- governance role also includes alignment with policy directives, accountability to funders, community, other stakeholders, and to different aspects of the healthcare system.

Into this complexity — and a longstanding lack of resources to meet our healthcare needs, particularly for the public sector — came the COVID-19 pandemic, now in its third year.

The strain of both primary care and aged care, with different funders and policymakers changing patient flows and bed priorities as the pandemic progressed, manifested issues for clinical governance. The chronic need for hospital beds for COVID-19 patients resulted in the cancellation of non-urgent services and surgeries. The result of these measures has seen increases in issues of late presentations of disease, and in staff issues of sickness, mental health and fatigue. It is increasingly apparent that without adequate numbers of healthy and appropriately credentialed staff, corporate performance is affected.

Healthcare governance has clearly been thrust into the spotlight and was selected as a session for discussion at the recent 2022 Australian Governance Summit in Melbourne. The session identified the following issues for healthcare directors to consider for their organisations going forward. They apply at least equally to a strained aged care sector in need of urgent attention.

While answering these critical questions will be the subject of much debate, it is vital attention is focused on these priority areas to enable equitable, sustainable and positive healthcare outcomes for patients and practitioners, and for good business performance of the organisation.

1. Workforce shortages

It is now evident that Australia as a whole, and particularly in specific areas, does not have adequate numbers of appropriately trained and credentialed nurses, doctors, specialists and allied health workers (among others), to undertake the current and future work of many health organisations.

Training and credentialing are key aspects undertaken both in health organisations and by external providers for which the healthcare provider may not have oversight, for example, in universities and community settings. Training a specialist doctor takes 12–16 years, so urgent replacement of specialists is not easy. Overseas-trained doctors are now not easily available to support our workforce gap. Although there is an immediate need in major cities, the problem is magnified in regional areas, with some hospital services having to close.

2. Staff wellbeing

The “great resignation” has already been keenly felt in healthcare. Clinicians are accustomed to the high workloads and constant stress associated with burnout. However, the ever-increasing acuity, societal expectations and complex regulatory environment of healthcare provision have taken a toll on our workforce. This is potentially tied in with issue one (above), as all of these contribute to unexpected and large workforce issues. As more clinicians move away from patient-facing roles, or leave healthcare altogether, those who are left behind face mental health and wellbeing issues at great cost to themselves and the corporate goals of the organisation they work for. Healthcare boards must prioritise and protect the wellbeing of their employees as one of their greatest, and potentially scarcest, resources.

3. Occupational health and safety

A sufficient and healthy workforce is a key foundation for optimal organisational performance. Without an adequate workforce there are poor patient outcomes. It adds additional risks to patients and to clinical governance performance, in turn affecting total risk for the organisation. Boards must consider their risk-compliance appetite — what is their risk for inadequate staff levels, patient care and treatment delays? For private hospitals, reducing services is possible. However public hospitals must accept all patients needing admission and find them a bed. Yet if the referral system is not working well due to primary care pressures, this becomes a bed block in the hospital and a reduction in services. This has also seen the aged care sector unable to accept patients in a timely manner.

4. Culture

This is a difficult one because not only are there age-old cultural and behavioural differences between health disciplines, but also between and within roles in hospitals. Many senior healthcare workers on public hospital boards are appointed long after retirement from a clinical role and may not have the flexibility and speed to manage navigating all the issues that come up on a daily basis, particularly during a pandemic. There is a need to work cooperatively going forward — for example in IT, cyber, allocation of complex work and training staff requirements. We ask: where is the risk vs compliance or the innovation barometer now set on our boards for culture? Does this need to be reset for pandemic times? Do we even know or aim to predict what the health workforce is going to look like in the future, and how our teaching and training will need to adjust?

Issues where this was evident in the pandemic included the use of the same pre-pandemic systems for medical research funding processes, including: a reliance on large, long, expensive, randomised clinical trials, which were already being undertaken in other countries; lack of ability to use and link administrative data between Commonwealth and states, between states, within states and even within health districts and primary care; slow and tortuous ethics processes unaltered for the pandemic; difficulty with processes to physically move staff around to fill shortages; use of other digital services (for example, medical records are still paper-based in many hospitals); integration of new technologies to manage workload and measure care; and harnessing innovative spirit, creativity and decisions regarding infrastructure.

One major risk management issue is how clinical systems develop and support electronic medical records/consent processes, and how to navigate these processes and respect patient confidentiality.

5. Relationship between health and other entities

What are the clinical governance risk and compliance issues to be overcome? For example, for hospitals when their staff are trained by medical schools and universities, and their specialists by colleges, themselves accredited. And these subsequently accredit health workplaces for being able to deliver healthcare and train staff.

But how does the board provide oversight and monitoring here? How does the board navigate this? How does the healthcare organisation navigate through specialist college issues such as workforce shortages to ensure such requirements are met in a timely capacity?

6. Role of state/federal governments in health governance

Australia needs to have a pandemic strategy for the next and subsequent pandemics; and health policies need to be developed to support health organisations. Issues where healthcare had difficulty navigating government policy during the first COVID-19 wave were seen in the personal protective equipment issue, our vaccine roll-out strategy, our strategy for medicine supply chain issues and the lack of a mRNA vaccine technology facility. Strategic planning for workforce sustainability is a critical element of the future of healthcare and must be recognised as a primary policy priority.

7. Climate change?

COVID-19 hit at the same time as the natural disasters of fires and floods in Australia, causing an immense impact on the health and wellbeing of the population. How can issues around reduced wastage, sustainability and the effects of high temperatures on mosquito-borne viruses — which have added to the stress and sickness of our communities — be addressed at a health board level, for our important community stakeholders?

8. Therapeutics/supply chains and medicines manufacturing

Lessons here are around agility in our research systems and research funding processes, for example, the UQ vaccine project, the lack of cooperation and national coordination across the health and medical research sector; inability to use and combine administrative data; and problems with data linkage across states, and between primary and secondary health.

9. Appointments to health boards

In most states, public hospital boards are appointed by and accountable nominally to the minister; process and vetting is done elsewhere. In situations such as a pandemic, should some board members have a risk-compliance meter that is set lower than the general board? Or requirements for personality traits of agility, flexibility and innovation. Who are health boards accountable to, not just in law or regulations, but morally and ethically? How does a board set the tone from the top on culture, wellbeing and ensuring clinical outcomes are priority?

10. Organisational relationship with governance/health system structures

Lastly, it is important to consider how the board is affected by Commonwealth/state health committees and their policies and directives. Are our health workers trained to the required standards and able to be retrained (perhaps by external providers) as the needs of the health system changes? Do we have enough to deliver our services at the levels expected of us by our stakeholders. What control do we have over patient flows into and out of our hospitals? And how do changes in government policy for our stakeholders, such as aged care, affect us being able to deliver our healthcare? We believe healthcare and its governance are at critical times.