REFLECTIONS ON THE UNIQUE MACQUARIE UNIVERSITY HOSPITAL
Instrumental in establishing the first private hospital on an Australian university campus, Professor Michael Morgan retires this year. Professor Morgan is an internationally recognised neurosurgeon for complex brain conditions, and has operated on more cerebrovascular cases than any other neurosurgeon in Australia – including more than 3,000 aneurysms and 800 arteriovenous malformations. He became the first Dean of Medicine at Macquarie University in 2006. We spoke to him about the Macquarie University Hospital journey and this one-of-its-kind healthcare model in Australia.
Q: Macquarie University Hospital introduced a new model for hospital care in Australia, and you did a lot of work in finding the right approach and establishing it. Can you tell us about the drivers behind the Hospital’s model?
Australian hospital care is world class – both public and private. And we should be proud of what we have achieved. Looking ahead, though, we face an enormous challenge in keeping up with the explosion of knowledge in medical procedures and technologies. We’re talking about double-digit per cent increases annually – much of this taking place in big medical research and clinical centres overseas.
Typically, the newly qualified specialist in surgery or medicine goes overseas to acquire skills and knowledge, returning to Australia to put into practice the latest medical and surgical developments.
I was one of those US graduates myself – having completed a Fellowship in neurosurgical training at Mayo Clinic – and I saw how learning and discovery at the highest level were an integral part of a clinician’s role.
What we were missing in Australia was the ability to be a player in that space, to contribute to global medical innovation in a significant way.
If you look at the great medical schools in the US – Harvard, Mayo Clinic, Johns Hopkins and UCSF, for example – they all have in common what we now have at Macquarie University Hospital. In each of these top medical schools, the hospital and university are highly inter-related in a way that merges exploratory work with clinical practice and education.
These medical schools become a magnet for clinicians wishing to be innovators, teachers and leaders. These clinicians share a common goal: to heal, learn and discover. These are enmeshed not only in the expectations of the position and the relationship with their academic and clinical employers but in the organisational culture and structure.
So this was the driver behind the Hospital – and to achieve this by becoming the first Australian university to own and operate its own hospital. And I believe that, after eight years, that vision has been achieved – in large part because we built it from the ground up with full alignment between research, education and clinical work.
Q: Take us back to the early days. Who were the early players, people who perhaps are no longer here but who laid the foundations and had the vision for Macquarie University Hospital?
John Lincoln, who was one of the most important founders of Macquarie University, said to me that Macquarie would never be a real university without a medical school. The actual proposal for a hospital to be built on campus, however, emerged from a chance meeting between Carl Adams, then CEO of Dalcross Hospital, and Ian Briggs of Macquarie University.
Prior to my appointment in 2006 as Dean of the Medical School, I met with Di Yerberry, Vice-Chancellor at the time, and she was very keen – as was Jim Piper, then DVC Research – to progress the idea of a hospital as part of the ongoing conversation on expansion of the university and use of its land assets.
When Stephen Schwartz became VC in 2006, the project was crystallised and brought into existence. There was broad support from the university for a Medical School to be associated with the hospital proposal as this was seen as a way to attract the prestigious NHMRC funding at a time when Australian Government funding for research was declining.
So it was through this that the project was born and a joint venture with a hospital was put on the table as an innovative model for medical research, education and clinical practice.
In early 2009, almost certainly as a consequence of the 2008 recession, significant decisions had to be made about the continuation of the joint venture with Dalcross Hospital that threatened to scale back the project.
The aim to achieve the most advanced hospital in Australia, however, was paramount. And the GFC, in effect, precipitated one of the most important decisions by Steven Schwartz and the University Council: to continue with the original vision but for the University to take over the ownership of the project entirely.
Thus, Macquarie University Hospital became the first university-owned and run hospital in Australia. The potential synergy between the University’s goals in innovation and learning could therefore be coupled to the hospital’s goals to heal and care.
I can remember the day that I addressed the University Council on the reasons why they should take the bold step and own the project. I remember where Evan Rawstron and I were sitting in the round room and it was one of the most stressful presentations that I have ever made. If I did not deliver well, I thought that Australia would be deprived of a new model of hospital practice that was ideal for medical leadership.
Q: What can you tell us about the physical place – the hospital environment and the medical infrastructure that was built and installed – and its impact on achieving the model you envisioned?
Advanced technology, systems and accommodation were crucial to realising the vision and the University did not compromise on facilities.
Included in this were the world’s best imaging capabilities, a cyclotron for isotope generation, the first gamma knife in Australia, a paperless records system, 20-bed intensive care, state-of-the art operating rooms with the most advanced facilities such as intraoperative CT cans and angiography with an ability to record all performances.
These things were all essential not just for excellent patient care but also for education and research purposes – core components of the model.
The patient accommodation is very comfortable and extremely advanced and contributes to the notion of excellence in all things patient related.
Q: What were your most anxious moments in establishing the Hospital?
There was a lot riding on the 2009 decisions being made in Council. As Dean, I was making the case for our preferred model of university ownership of the hospital and I knew that if I didn’t do a good job, the hospital component could have been sold to another hospital operator. Had this happened, we would not have achieved the advanced and integrated research, education and clinical model that I so desperately wanted.
Then, of course, doing the first operation in June 2010 was a momentous point. It all went very well and we moved forward from there.
Q: What are you most proud of?
The calibre of clinicians nurses and medical staff, without a doubt, and our ability to recruit the best surgeons, physicians, anaesthetists, researchers and biomedical minds.
In the typical hospital in Australia, only a small percentage of the consultant staff is engaged in a commitment to innovation. What we’ve been able to do is form established teams across many disciplines to create a great depth and breadth of contributors with a commitment to creating new knowledge and facilitating learning within the umbrella of MQ Health.
Once you have a significantly sized team, you can make the case for NHMRC funding and really create new knowledge. This is not possible for clinicians to do in isolation. I think Neurosurgery is an example of achieving such a successful group, where income is being generated to support degree fellows, provide educational opportunities and establish a long-term research focus with tangible life-changing outcomes based on new medical discovery. Our AVM work, led by Marcus Stoodley, for example, is world class.
It’s a real matrix when you look at the multi-disciplinary involvement in many areas: surgeons in the Biomedical Laboratory; Motor Neurone Disease clinicians turning to zebra fish models; AVM researchers looking to proteomics; clinical epidemiologists collaborating with statisticians – the possibilities are huge.
I’m also absolutely delighted at the outstanding nursing staff, indeed all staff, who contribute to the quality of patient care that we are delivering. Under the leadership of CEO, Carol Bryant, and the Executive Dean of the Faculty of Medicine and Health Sciences, Patrick McNeil, the culture of heal, learn and discover is now entrenched and makes this hospital unique, important and a leader.
Q: What would you like to see achieved in the five years after you leave?
I think that tangible and transparent metrics can drive an improved performance. We see this in sport, business, education and many fields. However, in medicine, the norm is that outcome data is not in the public domain. Claims of excellence are hollow unless measured against something. I would like to see each clinical unit define what a favourable outcome for their clinical practice is and for this to be on the Hospital website with how the unit is performing.
As an example, you can define a favourable outcome following intracranial aneurysm treatment as an effectively treated aneurysm without new neurological deficit. I would expect that 95 per cent of patients should be able to be included in this outcome. The hospital website could provide these results and this could be updated quarterly. This would allow clinicians, future patients and the public to judge our performance. We can then be benchmarked against the world’s best practice and we can identify where we need to improve.
An adverse performance would create some urgency in understanding and putting in place efforts to improve this performance. Of course, if more complex work with higher complication rates may distort this picture, but if a standard complexity is defined then benchmarking is fair. Therefore, I think there is urgency for audits to be made available for patients and the public to judge the Hospital’s performance.
Q: Is the Macquarie University Hospital model one that can, or should, be adopted in other states around Australia?
I believe that the model of university-owned and run hospitals has a common purpose of team-based demonstrable excellence of care. All in the organisation striving for this purpose and measuring new projects against this purpose will improve the likelihood that this can be achieved.
Alternate hospital models usually find a clash in roles. Many private hospitals see the surgeon as the main customer ¬– rather than demonstrable excellent patient outcomes as the goal – and many public hospitals have resource constraints that create tension between the role as tertiary referral centres and local community hospitals. Therefore, the model of a university hospital may achieve the goal of team-based demonstrable excellence of care with greater certainty.
It would be great to see more universities pick up the challenge and try to emulate what Macquarie has achieved. However, with university politics being what they are, this would be very difficult to achieve for a university with an existing medical school. Overcoming the various vested interests to make change would be a very difficult challenge. For universities without a medical school, to develop a medical school is equally difficult.
We are very fortunate with the leadership of Patrick McNeil that a very exciting model of medical school has now been established at Macquarie University. The reality is that the Macquarie University model, whilst logical, was also very dependent on a unique combination of circumstances at the right time.
I would say that the most likely way that this university hospital system will grow is with Macquarie University itself. The current hospital is small and could be expanded. The services could be increased. And it may be possible to establish Macquarie University Hospitals both in NSW and interstate.
Furthermore, Macquarie University Hospital – perhaps under the banner of MQ Health – should become a service for Southeast Asia. Mayo Clinic now cares for 1 million people per year employing nearly 4,000 doctors and scientists at various sites. It started in the 1880s, 100 miles by rail and buggy ride from the nearest large population centre in the middle of the cornfields in southern Minnesota. It become world famous within 20 years of the foundation being established by the Mayo brothers. I believe that they had greater barriers to achieving their current size and excellence that we have at Macquarie University. I believe that we should be the Mayo of Australia and Southeast Asia.