Leading the Safety and Quality Agenda in Australian Health Care Coalition of National Nursing Organisations Chris Baggoley 2 May 2008

Quality in Australian Health Care Study “A furore erupted in mid-1995 when a former Federal Minister for Health, Dr Carmen Lawrence, released preliminary results of a study estimating that 14,00 people died in Australian hospitals each year as a results of complications in their health care. The public was alarmed, and doctors were furious.” Sydney Morning Herald: 2/12/1997

ACSQHC The Australian Commission on Safety and Quality in Health Care - Established by Health Ministers in 2005, commenced in Reports to Health Ministers - Commissioners diversity and strength - Committee structure:  IJC, PHSC, PCC, ISC  Enactors - Stakeholders / Colleagues include:  Consumers  Professional organisations  Health Service Executives

ACSQHC Our Priority Programs 1. Patient Charter of Rights 2. Open Disclosure 3. Basic Care Issues - Hygiene - Patient Identification - Medication Safety - Handover -Patient at risk -Falls 4. Tools - Accreditation and credentialing - Quantitative & Benchmark Measures - Harnessing IT & Communication

 DRAFT: Australian Charter of Health Rights What can I expect from the health system? MY RIGHTSWHAT THIS MEANS 1. SAFETY: I have a right to safe and high quality care Safe and high quality health services provided to me with professional care, skill and competence 2. RESPECT: I have a right to respect, dignity and consideration Care that respects me and my culture, beliefs, values and personal characteristics 3. COMMUNICATION: I have a right to be informed about services, treatment, options and costs in a clear and open way Open, timely and appropriate communication about my health care provided in a way I can understand 4. PARTICIPATION: I have a right to be included in decisions about my care I may participate in making decisions about my care and about health service planning 5. PRIVACY: I have a right to privacy and confidentiality of my personal information My personal privacy is maintained and proper handling of my personal health and other information is assured 6. COMMENT: I have a right to comment on my care and to have my concerns addressed I can comment on or complain about my care and have my concerns dealt with properly and in a timely way 7. ACCESS: I have a right to health care I can access services to address my health care needs

ACSQHC PATIENT CHARTER I have a right to safe and high quality care I have a right: -To be free of being infected by my hospital or health worker -To be free of medication mishap -To be assessed for the risk of VTE -To have the correct procedure, operation, test, x-ray -To be rescued if my condition unexpectedly deteriorates

Evidence based risk assessment for VTE Evidence based risk assessment for DVT is disappointing despite national and international research. Mortality due to DVT after hospital admission is 10 times greater than after MRSA. Responsibility for assessment and prescription of prophylaxis are often confused.

ACSQHC PATIENT CHARTER I have a right to clear communication throughout the period of care I have a right: - For my health information to be passed accurately between settings and shifts of care - To be told what happened when things go wrong

ACSQHC PATIENT CHARTER Patient rights ACSQHC response By this time next year we will have…

Open Disclosure This time next year, we will have: - The open disclosure standard endorsed - Provided tools to assist jurisdictions and private sector implement the standard Legal consistency Patient stories Patient support material Implementation guide for health care facilities - Published open disclosure evaluation in the peer reviewed literature

 Health Care Associated Infection This time next year, we will have: - Infection Control Guidelines updated and disseminated - Nationally agreed standards for: Surveillance of hospital infections Monitoring resistance to antibiotics Use of antibiotics - Empowered Infection Control Practitioners to effect change in their facilities

Patient Identification This time next year, we will have: - An agreed national standard for patients ID - Spread the 3Cs nationally to other areas, such as: Radiology Radiotherapy Dental care - Disseminated learnings from patient ID adverse events

Clinical Handover This time next year, we will have: - Completed national projects covering 4 areas: Specific handover processes Electronic tools Communication and team training Tools for observation, monitoring and evaluation and handover - Commenced national spread - Advised international community - Disseminated learning from clinical handover adverse events

Medication Safety This time next year, we will have: - Spread the National Inpatient Medication Chart to the following areas: Paediatrics Long stay Specialist areas (eg insulin administration) - Audited the effectiveness of the NIMC in jurisdictions - Spread the VTE prophylaxis program to the private sector - Assisted GPs manage warfarin medication - Described and started to address other key medication safety gaps

Accreditation This time next year, we will have: - An alternative model for accreditation - A preliminary set of Australian Health Standards - Reviewed surveyor participation - Conducted research into patient journeys and unannounced surveys - Defined a process of national coordination of accreditation

Information Strategy This time next year, we will have: - Developed operating and technical standards for Australian Clinical Quality Registries - Developed national indicators for safety and quality - Recommended to Ministers national data sets for safety and quality - An understanding of the economic costs of patient injury

Not only but also This time next year, we will have: - The 2008 National Report - Led and coordinated a national approach to credentialing - Commenced a national approach to detection and response to the patient at risk

ACSQHC PATIENT CHARTER Patient rights ACSQHC response But how will this make a difference? To ConsumersTo Clinicians

ACSQHC Consumers Patients Citizens Experience, wisdom, knowledge and views Health Ministers Actions to make health care more patient centred, to improve safety and quality States and Territories, and their public hospitals State/ Territory Safety and Quality Organisations Private Sector Primary Care Sector Health Care Complaints Commissioners Regulators Australian Commission on Safety and Quality in Health Care Consumer Engagement

ACSQHC SAFETY: Safe and high quality care Patients, consumers and health care providers are entitled to a safe, secure and supportive health care environment. Patients and consumers have the right to expect that safe care and treatment will be provided in every encounter with the health system. Some of the ways you can contribute to the provision of safe and high quality care are by:  Tell staff if you think that an error might have occurred or something has been missed in your care Patient or Consumer  Provide health care services with professional skill, care and competence  Provide health care services that are informed and where possible, evidence based  Participate in patient safety systems established by the health service organisations in which you work  Provide health care services with professional skill, care and competence  Provide health care services that are informed and where possible, evidence based  Participate in patient safety systems established by the health service organisations in which you work Health Care Providers  Ensure that health care providers are appropriately qualified, competent and experienced, and that facilities and procedures meet industry standards  Ensure that health care providers have the resources to allow them to provide safe, effective and appropriate health care  Ensure that systems are in place that promote patient safety and that instructions to patients and consumers are clear and well communicated  Ensure that health care providers are appropriately qualified, competent and experienced, and that facilities and procedures meet industry standards  Ensure that health care providers have the resources to allow them to provide safe, effective and appropriate health care  Ensure that systems are in place that promote patient safety and that instructions to patients and consumers are clear and well communicated Health Service Organisation

Literature On the Trail of Safety and Quality in Healthcare Richard Grol, Donald Berwick, Michael Wensing BMJ 336 (2008) Major problems persist to improve the quality and safety of healthcare Factors include: - Resistance to change among health professionals - Organisational structures that block improvements - Dysfunctional financial incentives Research agenda topics suggested

Literature On the Trail of Safety and Quality in Healthcare Richard Grol, Donald Berwick, Michael Wensing BMJ 336 (2008) Research agenda topics suggested include: - How to achieve sustained change in normal care - How to guide clinicians towards scientifically correct and safe practice - How to provide new evidence at the point of care - How to create a culture of change and continuous improvement in the ward or practice

Organisational Factors “There is growing evidence base of rigorous evaluations of organisational strategies, but the evidence underlying some strategies is limited and for no strategies can the effects be predicted with high certainty.” Wensing M, Wollersheim H & Grol R Implementation Science, Organisational intervention to improvement in patient care : a structured review of reviews

Organisational Factors Organisational interventions to improvement in patient care : a structured review of reviews Revision of professional roles FocusMain results Nurse practitioners in primary care ( 13 trials) Improved: laboratory testing, resolution of pathology conditions, patient satisfaction No change: quality of care, prescribing functional status, consultation rates, use of emergency service Nurse practitioners in primary care ( 13 trials) Improved: patient satisfaction Increased: consultation length, investigations No change: health status Mental health workers in primary care (38 trials) Replacement role: did not consistently change psychotropic prescribing, consultation rates or mental health referrals Enlargement of the role of the public pharmacist (16 trials) Changed: use of health care services, improved patient outcomes No change: quality of life Outreach nursing for COPD (4 trials) Increased: hospital service use No change: mortality, lung function, health related quality of life

Organisational Factors Organisational interventions to improvement in patient care : a structured review of reviews Integrated care services FocusMain results Stroke Units (19 trials) Reduced: mortality, dependency, institutionalisation, length of hospital stay In-hospital pathways for stroke (10 trials) Fewer: UTIs, readmissions More: CT brain scans, carotid duplex Reduced: patient satisfaction, quality of life No change: mortality, dependency, discharge destination Disease management for heart failure in patients discharged from hospital (11 trials) Decreased: hospital use, costs No change: all-cause mortality

Organisational Factors Organisational interventions to improvement in patient care : a structured review of reviews Knowledge management FocusMain results Computerized information services in different settings Improved: test ordering/prevention in A, B & C Improved: drug prescription in D Improved: patient knowledge in E A.Provider prompt B.Provider feedback C.Computerized medical record D.Assisted treatment planning E.Computerized patient education (100 trials) Nursing record systems (8 trials) No change: patient care, patient outcomes Some: administrative benefits

Sun Herald – ‘simple jab’

Effecting Change Commission Private Hospital Sector Committee Information Strategy Committee Primary Care Committee IJC Safety and Quality Bodies Staff Clinical Quality Registries Committee CHF Consumer engagement Community AHMC AHMAC AIHW TGA CPMC NHMRC NICS NeHTA Nursing Orgs ACHSE Allied Health Orgs University Sector Prime Minister COAG National Health and Hospitals Reform Commission AMA Media Private Sector Advisory Committees Working Parties Research Sector