1. The Royal Australasian College of Medical Administrators Safety and Quality in Australian Health Care Dr Heather Wellington Member, Australian Council for Safety and Quality in Health Care Policy Advisory, RACMA

2. The Royal Australasian College of Medical Administrators Safety and Quality Known international problem Bristol Royal Infirmary Paediatric Cardiac Quality in Australian Health Care Study Periodic media focus on things that go wrong

3. The Royal Australasian College of Medical Administrators Safety and Quality Quality in Australian Health Care Completed 1995 10% of admissions associated with an adverse event 50% serious 50% preventable

4. The Royal Australasian College of Medical Administrators Safety and Quality Most common adverse events Wound infection Adverse drug events Falls Pressure sores

5. The Royal Australasian College of Medical Administrators Safety and Quality Costs of unsafe care significant Financial and other costs difficult to quantify Estimated more than $1 billion per year in direct costs and more than $6 billion per year in indirect costs Secondary victims include health care providers

6. The Royal Australasian College of Medical Administrators Safety and Quality ACSQHC 23 members, some representing jurisdictions, some personally appointed First met in February 2000 Annual reports to health ministers

7. The Royal Australasian College of Medical Administrators Safety and Quality Council’s role To lead and coordinate national efforts to promote systemic improvements in the safety and quality of health care in Australia, with a particular focus on minimising the likelihood and effects of error.

8. The Royal Australasian College of Medical Administrators Safety and Quality Safety First – Freedom from Accidental Injury Consumers aren’t interested in your journey to quality. They want safe hospitals. They don’t want to meet you at the beginning of your journey. Consumer Advocate

9. The Royal Australasian College of Medical Administrators Safety and Quality Safety First Quality message devalued with clinicians All doctors committed to the edict “First, do no harm” Safety first message accords with aspirations of doctors and consumers, BUT Many still question the legitimate role of managers

10. The Royal Australasian College of Medical Administrators Safety and Quality You ponce in here expecting to be waited on hand and foot, well, I’m trying to run a hotel here. Have you any idea of how much there is to do? Do you ever think of that? Of course not, you’re all too busy sticking your noses into every corner, poking around for things to complain about, aren’t you? Basil Fawlty (aka John Cleese), actor and comedian

11. The Royal Australasian College of Medical Administrators Safety and Quality ACSQHC Key Themes A systems improvement focus Greater openness An approach with “clout” Collaboration

12. The Royal Australasian College of Medical Administrators Safety and Quality Systems Improvement In a 26 component system, each component operating properly (no errors) 99% of the time, the probability of the whole system functioning correctly is 78% For 50 components, 61%

13. The Royal Australasian College of Medical Administrators Safety and Quality Systems Improvement Even apparently single events or errors are due most often to the convergence of multiple contributing factors. Blaming individuals does not change these factors and the same error is likely to recur. Preventing errors and improving safety for patients requires a systems approach in order to modify the conditions that contribute to the errors. People working in health care are among the most educated and dedicated workforce in any industry … the problem is that the system needs to be made safer. US Institute of Medicine. To Err is Human

14. The Royal Australasian College of Medical Administrators Safety and Quality Systems Improvement Medical culture personalises error and seeks and expects perfection Culture of self-blame leads to lost opportunities Doctors fearful of humiliation and professional or medico-legal consequences Blame perpetuated by public, media and courts

15. The Royal Australasian College of Medical Administrators Safety and Quality Greater Openness Consumers believe system is closeted and secretive when things go wrong International experience suggests considerable benefits from greater openness Open Disclosure project is a key plank of Council’s activities

16. The Royal Australasian College of Medical Administrators Safety and Quality An approach with “clout” Incentives will be required to create and sustain focus on systems improvement Sanctions should not be discounted when known risk factors and problems are not appropriately addressed

17. The Royal Australasian College of Medical Administrators Safety and Quality Collaboration A vast and complex task ACSQHC working closely with states and territories, professional bodies and consumer groups

18. The Royal Australasian College of Medical Administrators Safety and Quality Major Current Projects – 5 categories Supporting safe practice Redesigning systems Improving data and information Building awareness Involving consumers

19. The Royal Australasian College of Medical Administrators Safety and Quality Major current projects – supporting safe practice National approach to medical registration Qualified privilege Credentials and clinical privileges standard Standard setting and accreditation Safe staffing

20. The Royal Australasian College of Medical Administrators Safety and Quality Major current projects – redesigning systems Undergraduate and postgraduate education Patient safety roadshow (national workshops) Medication safety – multiple initiatives in progress Falls prevention – CD Rom National evaluation of Met systems

21. The Royal Australasian College of Medical Administrators Safety and Quality Major current projects – improving data National approach to sentinel events National procedural registers Tools and support for clinical audits National review of incident reporting and management systems National approach to healthcare related infections

22. The Royal Australasian College of Medical Administrators Safety and Quality Major current projects – improving data Implantable medical devices tracking system National approach to Coronial data National review of mortality and morbidity data sets Vocabulary of key safety and quality terms

23. The Royal Australasian College of Medical Administrators Safety and Quality Major current projects – building awareness Multiple publications on council’s website Scholarship program for major conferences Visiting international speaker program Business case for investing in safety and quality National patient safety research agenda

24. The Royal Australasian College of Medical Administrators Safety and Quality Major current projects –involving consumers Open Disclosure standard Trial of consumer line for adverse drug experiences (to commence 2003) Improving value of health care complaint information

25. The Royal Australasian College of Medical Administrators Safety and Quality Issues Financial and ‘in kind’ support from all jurisdictions All jurisdictions also pursuing individual efforts General focus is on tools for clinicians, consumers and managers to drive quality Jurisdictions and health insurers increasingly demanding compliance with safety and quality- related requirements

26. The Royal Australasian College of Medical Administrators Safety and Quality Issues ?need for other tools to facilitate/promote/ enforce better safety systems Role of senior managers – achieving appropriate responsibility/ accountability relationships with medical staff Board clinical governance responsibilities ?what does success look like