The NSW Guidelines (The Role Delineation Model)
Background
Over the 1980s, the New South Wales Department of Health developed a set of guidelines for measuring the services provided by hospitals and area health services. Entitled "Guide to the Role Delineation of Health Services", the guidelines were intended to provide an objective, standardised system for describing the scope and level of services provided.
To quote from the Guide itself,
Role delineation is a process which determines that the support services, staff profile, minimum safety standards and other requirements are provided to ensure that clinical services are provided safely and appropriately supported. The aim of the Guide is to provide consistent language which health care providers and planners can use when describing health services, and a tool for use when planning service developments. (CHEMU, 1993:1 07)
First used in New Zealand as the NSW model, a New Zealand version was produced in 1993 (CHEMU, 1993). However, the amendments were more in terms of nomenclature than substance.
The model sets out various levels for each clinical service, ranging from 0 (no service) to 6. Although it is descriptive rather than prescriptive, the guide specifies the level of support services (e.g. x-ray, anaesthetics, etc.) required for the corresponding level of clinical service. There are eight clinical support services, listed in Table 1. As an example, surgery performed at level 2 (minor diagnostic and therapeutic surgical procedures on good risk patients) should be supported by pathology at level 1, x-ray and pharmacy at level 2, and so on.
| Table 1 The Eight Clinical Support Services in the Role Delineation Model
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The guidelines cover six categories of basic clinical services: emergency, medicine, surgery, maternal and child, integrated community and hospital services, and primarily community health services. The level assigned to each service is determined by the complexity and frequency of the activity undertaken and the presence of certain suitably qualified health care personnel. Sample procedures are listed to indicate the type of activity undertaken for each level.
Strengths of the Model
Of the 10 health professionals contacted who had worked with the model, most described it as a useful tool. It provides a common framework for describing hospital services, which ensures that RHAs, CHEs and others can be 'talking the same language' when describing services.
This common framework means that the model is useful for co-ordinating services within an area. Hospitals may specialise in certain services, especially at the higher levels, while still ensuring that, between them, the hospitals in an area offer complete coverage for that area. This can avoid duplication of expensive technology while improving the expertise of staff in the procedures specialised in. It may also allow for better co-ordination and more use of visiting specialists. This co-ordination of service may be applied at a local, area, regional or national level. For example, there is work currently underway to use the model to co-ordinate accident and emergency services at a national level.
As a planning tool the guidelines also provide benchmarks for determining, as one consultant termed it, "what business the hospital is in" (Dutton, pers. comm.). It gives an unbiased inventory of what services are offered, and allows assessment of what gaps or discrepancies exist. This may indicate where more resources need to be directed, or it may show up areas where a service is not appropriate and should be discontinued. It can also be used to compare the services offered between different areas.
There is a degree of flexibility in the guidelines, which allows varying circumstances to be taken into account. Services are not required to be on-site, so that smaller hospitals may count services available at other centres, as long as the access to those services is such that patient safety is not at risk. For example, the requirement for a staff person to be on site may be considered met by a person on call, as long as that person can be on site within a specified time period. Similarly, services offered on an day-patient basis may be considered to count as corresponding operations offered on an in-patient basis, as long as the requirements for follow-up care, etc. can be met.
This flexibility means that the guidelines must be used with a certain amount of interpretation. However, there is a balance to be struck as too much leeway can render the guidelines meaningless, especially where used for comparison with others. In general, though, the guidelines serve to raise issues and ask questions, which it is then up to the assessors involved to answer.
Weaknesses of the Model
The most frequent complaint from those involved in using the guidelines was that they had not been sufficiently adapted to New Zealand conditions. This was particularly true with respect to community services, where opinions of the model ranged from "unwieldy" to entirely inappropriate. There was also concern that the criteria for surgery at the lower levels did not entirely suit the New Zealand context, and that work was needed on some of the definitions used. Given that some of the descriptions were first developed in Australia a decade ago, it was also considered that some updating was necessary.
It is important to note, however, that the guidelines issued by the Crown Health Enterprise Monitoring Unit (CHEMU) last year were considered to be a working draft. It was recognised that further development was necessary, and that the amendments necessary would become clearer with further use in the New Zealand environment.
It is also important to acknowledge that this model is just one tool used by providers and purchasers to determine whether services are being offered at an appropriate level. The guidelines examine only one part of total hospital operations, and do not address issues such as cost, efficiency or equitable access.
The model also focuses on inputs, rather than desired health outcomes. For this reason, it was considered inappropriate by one RHA for use in determining what would be purchased from CHEs, as RHA purchasing decisions are output-based (Taylor, pers. comm.).
The model does not evaluate the competency levels of staff, other than obliquely through assessing the frequency with which they perform certain procedures. And although the guidelines can be used as part of a quality control programme, they by no means constitute a sufficient programme in themselves.
Finally, the results obtained from applying the role delineation guidelines are not static, and the assessment should be carried out on a regular basis to take into account changing conditions at the hospital(s) under study.
Contact for Enquiries
Rural Affairs Coordinator
Sector Performance Policy
MAF Policy
Ministry of Agriculture and Forestry
PO Box 2526
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NEW ZEALAND
Phone: +64 4 894 0675
Fax: +64 4 4 894 0745
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