The six places a hospital COO's judgement is tested

Private health insurers fund about 70 per cent of our revenue through agreements that usually run for two or three years. Most of those agreements pay per episode, grouped by diagnosis-related group, with separate terms for prostheses, same-day care and rehabilitation. Each clause has an operating consequence. An indexation rate decides how many nursing hours per patient day we can afford; a per-episode price decides how long a patient can stay before we lose money; a readmission clause decides how carefully we plan discharge. Since 2021 I have co-led our negotiations with the chief financial officer. We bring a cost pack for each ward and each high-volume procedure, built by nurse unit managers and theatre managers rather than only by analysts. Our negotiators can now show an insurer exactly what a proposed price would do to staffing on a named ward, and I can tell a ward exactly why a contract reads the way it does.

Our 68 operating theatres account for most of our revenue and much of our clinical risk. A theatre session in a private hospital has traditionally belonged to a surgeon, often for decades, whether or not that surgeon fills it. I introduced rules in 2022 that change this: sessions released at least fourteen days ahead carry no penalty, and sessions used below 75 per cent for two consecutive quarters are reviewed by each hospital's surgical services committee and can be reallocated after a quarter's notice. Utilisation of booked sessions rose from 66 to 81 per cent by 2025. I also watch what limits theatres beyond the surgeon: anaesthetist availability, sterilising services capacity, recovery beds and the ward bed that must be free when the patient leaves recovery. In my experience the binding constraint moves, and a perioperative plan that watches only the operating list will miss it.

Our regional hospitals compete for nurses with public hospitals that, in Queensland, must meet minimum nurse-to-patient ratios on many medical and surgical wards. When the public system recruits to meet its ratios, our regional wards feel it within weeks. By 2022 agency nurses were working 11.6 per cent of our nursing hours, at about one and a half times the cost of an employed nurse, and ward teams changed from shift to shift. We built a relief pool of 140 employed nurses who rotate between our regional hospitals with paid travel and accommodation, agreed a regional allowance through our enterprise agreements and gave nurse unit managers authority to book the pool directly. Agency hours fell to 3.8 per cent in 2025–26, saving about A$19 million a year. I report agency share, nursing hours per patient day and unfilled shifts by ward to the board every quarter.

Five of our twelve hospitals are in regional towns where the public hospital is larger than ours and carries the emergency department, intensive care and around-the-clock specialist cover. I think a regional private hospital is most useful when it is designed around that fact. At Kelvarra Rockhampton we ended private births in 2023, transferred thirteen midwives to the public maternity unit and converted the space for public elective surgery, which the state buys from us under contract. We now perform 2,100 public procedures a year there. In two other towns we share an anaesthetic on-call roster with the public hospital and accept its overflow of day-surgery patients. These arrangements need clear clinical governance, agreed transfer protocols and written terms for who pays when a patient deteriorates. They also need trust, which I build by sharing our activity and complication data with public colleagues before they ask for it.

About 2,600 specialists hold admitting rights at our hospitals, and almost none of them are our employees. Clinical governance in a private hospital therefore depends on credentialing: confirming each doctor's registration with Ahpra, insurance, training and recent experience, and defining a scope of clinical practice that the hospital's medical advisory committee approves and reviews. I make sure the operating side supports that work: credentialing files that are current, theatre booking systems that will not accept a procedure outside a surgeon's approved scope, and a single register of serious incidents reviewed weekly by me and the chief medical officer. Our hospitals are accredited against the NSQHS Standards, and I treat assessment findings as operating matters with owners and dates. I also follow the open disclosure framework when care goes wrong, because patients and families deserve a straight account and an apology.

A hospital can lose its patient administration system, its pathology links and its insurer claims gateway in a single afternoon. In August 2024 an intruder used a supplier's support account to reach our network, and I decided, with the chief executive, to isolate every external connection across all sixteen sites for four days while the incident was investigated. Elective activity fell by about a third and A$41 million of claims were delayed. Since then I have treated downtime as a clinical capability rather than an IT recovery plan. Every hospital runs a paper downtime drill each quarter, covering admissions, medication charts, pathology results and theatre lists. Supplier access now passes through brokered, recorded sessions. We notified the OAIC, the federal privacy regulator, and affected patients under the Notifiable Data Breaches scheme, and our audit and risk committee reviews recovery times rather than counts of blocked attacks.