Volume 196 - Issue 4
Diamantina Health Partners: integrating leadership in research, research translation, education and clinical care
Authors: Jennifer H Martin, David E Theile, Ken K Y Ho and Ian H Frazer
Med J Aust 2012; 196 (4): 237-239. || doi: 10.5694/mja11.11251
Published online: 5 March 2012
Published online: 5 March 2012
“When you have seen one AHSC, you have seen just one AHSC” — Academic Health Sciences Centre, National Task Force Final Report1
Australia’s health system is struggling to meet demand and expectations. Demand is driven by an increasing burden of chronic non-infectious disease associated with ageing.2 Expectations of cutting-edge care for all are set by the public and by government.3 Meeting these demands and expectations will be possible only with substantial effort in research and education as part of health service delivery. Separation of funding for research and education from the delivery of patient care diminishes the opportunity for mutually enhancing integration, and for expenditure efficiencies.4,5
Recognising the importance of evidence-based clinical practice in quality and efficiency of health care delivery has been a driver for the creation of academic health sciences centres (AHSCs) in the United Kingdom6 and Canada.1 Australian commentary on AHSCs7 has emphasised an absence of government leadership in establishing AHSCs in Australia. It is critical to the success of AHSCs as a tool for optimal health care delivery that they are inclusive, and that they set performance benchmarks in service delivery, education and research, while neither aspiring to elitism, nor separating their activities from the provision of health care itself.
In early 2010 and 2011, a group of Brisbane hospital, university and community health care practitioners, administrators, educators and researchers had several meetings to consider the feasibility of establishing an AHSC. They recognised that some integration of education and research with service delivery was already occurring. A successful example of this was a hospital-based research program that had led to the development of cervical cancer vaccines,8 which had led to development of research facilities. This and other similarly successful programs were facilitated by leadership from individuals; however, an environment that encouraged activity by all practitioners was seen as likely to result in better outcomes in education, research and service. The meetings concluded that providing such universal support would improve health care, and further noted that failure to combine the three domains could be wasteful.
Several barriers to integration of education and research with service delivery were identified, which could be resolved by using a partnership model between local research institutions, public and private health care providers and educational facilities. Emphasising a partnership meant moving from a workplace focus to integrated management and service delivery structures across boundaries between primary and tertiary health care, and between education and research. The partnership model was chosen because governance was identified as key to realigning the purposes of hospital and academic institutions.9
Although it was hoped that merging many of the partners’ processes would occur with time, it was agreed that incremental changes in leadership and management structure could usefully start the process. These changes would be prioritised in terms of their potential to have a positive effect on health outcomes and resource efficiency. Developments in health and hospital reform and the release of a National Health and Medical Research Council position paper on designation of Advanced Health Research Centres in 2010, to which the group provided comments, helped launch the Diamantina Health Partners (DHP) in mid 2011 as an AHSC. This partnership brought together the University of Queensland (UQ) PA-Southside Clinical School, UQ Diamantina Institute, UQ general practitioner partners, research and teaching components of the Queensland University of Technology (QUT), the newly created Translational Research Institute (TRI), and health service delivery units from the Princess Alexandra and Mater Hospitals.
The partnership is a functional (not legal) one, with relationships and governance determined by a signed memorandum of understanding (MOU). The MOU covers the following issues relating to governance:
The DHP board is entrusted to explore options for the best organisational vehicle for the DHP (which in time may become a separate legal entity).
Sufficient internal resources will be committed by the partners as appropriate to achieve outcomes, with each (except the TRI) making an initial financial contribution for the development of the DHP.
Financial contributions may be varied by mutual agreement of the board.
The initial financial commitments of the DHP are the costs of a senior administrative consultant and workshops for strategic developments. All income remains with the participating entities. The board is to formulate and control administrative and strategic development.
Mission and vision
The major aim of the DHP is to integrate research, teaching and training with clinical service delivery, to enable internationally benchmarked, quality health care to be delivered in a timely and cost-effective manner. We recognise that complete integration is not realistic, but believe that mutually beneficial strategic decisions at university and hospital levels will facilitate achievement of the vision. Initially, we will align the strategic goals and plans of DHP stakeholders with expectations of patients using DHP services, for which we established six principles of development (Box 1).
Planning coordination is pivotal to the success of the DHP, and we believe education of clinical staff in research will encourage critical evaluation and application of new ideas and therapies in clinical care — skills to improve hospital performance in key performance indicators relating to efficient use of health care infrastructure (Box 2). Staff discussions about conjoint appointments facilitating teaching, research and clinical services are underway between the partners.
Current situation
One of our most pressing problems is engagement and representation in the DHP, which we are using our committee structure, reporting system, discussion groups and user groups to address. Early success in engagement is evident in collaboration on draft proposals and in facilitation of clinical research (by building clinical trial enrolments into performance indicators of service providers and departments). Engagement success is also seen in the teaching of medical, allied health and nursing students about clinical research methods, and by facilitating encounters between clinicians and basic researchers. Engagement is important from the strategic and survival perspectives of the DHP, and various strategies to benefit health and working environments are being planned. The ability to address new barriers is also crucial to success.
Another issue is that although the DHP board needs to have strategies in the best interests of the DHP, some partner representations on the board will be necessary, at least initially. The long-term aim is to have the right mix of people and skills acting in the interests of the DHP. An appropriate policy for membership of the board and its committees is being developed, as is a structure for successful implementation of DHP strategy into practice. Clear governance lines between the board and the partners will be necessary. Lastly, board diversity needs to be considered. The increasing number of women who are clinical academic leaders in Queensland will help achieve a balance of sexes. Care must be taken not to change organisational structure unless changes are clearly linked to improving health outcomes.
Areas under consideration include harmonisation of job descriptions and salaries between employment agencies, transparency of data and information technology services, and standardisation of intellectual property and commercialisation management. Setting research and policy priorities is underway.
An evident failure to deliver the vision espoused in the original 2010 proposal for health reforms threatens the existence of AHSCs, as federal funding for research, education and health remain separated. It is expected that the DHP will be politically independent and the board will be accountable for policy delivery and efficient use of public funds. The outstanding issues to be resolved by the DHP board are engagement; structural and policy “levers” it can use to influence institutional strategies; and ensuring strong alignment between the DHP and its individual components.
Summary
Many have asked “what is the benefit of the DHP over the current situation?” We believe that the responsiveness of research to community health needs and the balance of research and teaching outcomes in academic institutions can be improved, and stronger incentives to integrate research outcomes into clinical practice can be provided. The DHP is thus set up differently to a clinical research centre. The aim of our DHP is to improve health outcomes by means of coordinated excellence in teaching, research and clinical care. Technical efficiencies and excellence in care mean that financial efficiencies will occur. Joint clinical, research and teaching initiatives are underway, and plans are being developed to teach future clinical staff the science of clinician-directed, rational use of medical resources. These include pathology, imaging services, pharmaceuticals and patient referrals, assisted by published expert guidelines. There are significant administrative and personnel issues to surmount, but planning for integration has begun, and plans for turning research outcomes into clinical care plans are already emerging.
1 Six principles of development
The Diamantina Health Partners (DHP) will work towards:
1. A joint governance structure promoting a coordinated effort towards better health care. The DHP governance structure is based on a partnership — a non-incorporated joint venture. This structure enables partners to honour obligations to other entities. Functional integration is supported through joint appointments and creation of joint activity streams.
2. Jointly determined key performance indicators (KPIs) in patient care, education and research. Traditional measures of research focused on publications and of teaching based on student assessment were felt not to provide an ability to measure relevant contributions to health outcomes or “quality”.
3. A jointly agreed strategy for improving health care, focused on health and wellbeing.
4. Administrative processes aimed at accelerating dissemination of research-based evidence into clinical practice.
5. Collaborative use of public resources with public accountability. Cost-effectiveness is part of DHP strategy. Collaborations that ensure the best use of public resources and public accountability are encouraged. Reporting towards KPIs that relate to measurable health improvements will be introduced.
6. Common drivers encouraging development and improvement of clinical innovation, training and health policy. Proven strengths on the DHP campuses will be used as exemplars for setting aims and employment standards at an international level.
2 Clinical issues that could be improved with better linked education and research
Role of emergency department for multiple attenders and for people with chronic conditions
Bottlenecks in internal medicine discharges and the primary–secondary health care interface
Providing health care for areas of high medical need, such as bariatric surgery versus a proliferation of obesity clinics in tertiary hospitals
Use of expensive pharmacotherapies that have not been proven to meet clinically relevant end points, and which may cause high rates of adverse drug events
New research tools such as genomics for predictive management of disease or response to drug therapies, streamlined by information gained from health services research in a particular health district
Competing interests
No relevant disclosures.
Acknowledgements
We thank Ms Areti Gavrilidis and Ms Breeann Silvester for literature research and access to advice about international AHSCs; and Professor Ross Young, QUT Institute of Health and Biomedical Innovation and founding partner of the DHP team, for his leadership, support and expert manuscript suggestions. The original signatories to the Southside AHSC (a predecessor of the DHP) were Jennifer Martin, David Theile, Ian Frazer and Dr Richard Ashby, Chief Executive Officer of Princess Alexandra Hospital.
References
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- Australian Life Scientist. Ian Frazer named Australian of the Year. Sydney: Australian Life Scientist, 2006. http://www.lifescientist.com.au/article/148922/ian_frazer_named_australian_year (accessed Jan 2012).
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Provenance: Not commissioned; externally peer reviewed.