1. Health Quality and Safety Commission

2. HQSC role and purpose
To lead and coordinate work across the health and disability sector for the purposes of:
monitoring and improving the quality and safety of health and disability services
helping providers across the health and disability sector to improve the quality and safety of health and disability services

3. How the Commission adds value
Shining the light on variation, and key areas for improvement
Being an intelligent commentator and advocate for change
Lending a hand by making expert advice, guidance and tools available
17/09/2018

4. HQSC strategic priorities
Monitor and report on quality & safety
Build sector capability for quality & safety improvement
Support clinicians to be leaders of quality and safety improvement and follow best practice
Build consumer engagement and partnership
Support reporting & management of health care incidents
Manage mortality review functions
Influence the health quality and safety agenda and be a catalyst for change
Ensure success in our programme areas:
Medication safety - reducing harm from falls
Perioperative harm - Infection, prevention & control

5. A picture of mortality review

6. Reportable Events focus so far
Annual Serious Adverse Event Report, and Serious Mental Health Event Report
Establishing relationships across health and disability sector
Improving the scope and quality of reporting. Private hospitals
Implemented RL6 system within HQSC
Appointed David Sage as Clinical Lead and established an Expert Advisory Group
Developed a strategic work-plan

7. Trigger Tools 2014/15 ADE / GTT embedded in all DHBs
Improvement work integral part of all DHBs ADE / GTT work
Support for on-going sharing of data through:
site visits
active network
Strong regional networks with clinical leads
Explore potential for linking GTT & SAE programmes
Work with CMH Safety in Practice Programme to pilot a Primary Care TT
Links established with international community through IHI Forums

8. Medication Safety priorities
Safer prescribing, dispensing, administration and monitoring of medicines
National Medication Chart and electronic prescribing and administration
Improving the transfer of medicine information at transition points of care
Paper based and electronic Medicines Reconciliation
Partnership with the National Health IT Board for eMedicines Programme

9. Medication Safety priorities
Reducing harm from high-risk medicines and situations
Alerts, look-alike sound-alike medicines eg tall man lettering, labelling, health literacy
Scoping of improvement programme for opioids
Providing expert advice and strategic thinking on medication safety
Med safety watch, networks, contribution to strategy, evaluation of Hospital eMedicines implementation

10. Reducing harm from falls
730 serious adverse events, 365 patient falls, 170 falls associated with a hip fracture ( DHB SAE reports)
The direct costs of patient falls in hospitals for was between $3-5 million
Interventions highlighted as part of the campaign:
Risk assessment
Individualised care planning
Safe environments
Vitamin D
Strength and balance

11. Healthcare Associated Infections
Up to 10 percent of patients admitted to hospitals in developed countries acquire one or more infections during their stay.
Approximately 30 percent of patients in intensive care units (ICUs) are affected by at least one HAI (WHO, 2011).
HAIs can cause severe complications, and even deaths, particularly among people with pre-existing conditions.
In the late 1990s, the costs of dealing with these infections in our public hospitals were estimated at $137 million per year

12. HAI focus so far Hand Hygiene programme:
Compliance rates have increased from 62.1% (Oct 2012) to 71.2% (June 2013)
Central Line Associated Bacteremia (CLAB) Programme:
CLAB infection rates have decreased from 3.5 per 1,000 line days to 0.44 per 1,000 line days.
Surgical Site Improvement Programme
Established and collecting data from 20 DHBs
Current focus on hips and knee surgery expanding to cardiothoracic surgery soon

13. Surgical site infections
Occur in approximately 2–5 % of patients undergoing inpatient surgery
A patient with an SSI costs approximately twice the amount of a patient without an infection.
SSIs following joint replacements are strongly associated with increased morbidity & mortality, prolonged hospital stay & long-term antibiotic treatment
SSIs following open heart surgery extend the length of hospital stay by an average of 32 days at an average cost of NZ$45,000 per patient
Interventions highlighted as part of the programme to date:
streamlining the surveillance process
appropriate prophylactic antibiotics, right time, drug, dose
skin preparation
clipping not shaving

14. Perioperative Harm
What is it and how can we reduce it?

15. Reducing perioperative harm
An undesirable outcome (harm) associated with any aspect of an operation (intervention)
Preoperative
Intra-operative
Post-operative
Slips, lapses (omissions), mistakes and violations leading to harm

16. Perioperative harm includes
DVT/PE
Wound infection
Medication error
Wrong side/site surgery
Retained objects
Falls
Any other complication

17. Reducing perioperative harm
Facts and figures
Over 300,000 publicly funded operations are performed in New Zealand each year
ACC accepts between 20 and 50 claims per year for personal injury due to surgical error.
Perioperative harm events made up 36 percent of non-mental health serious and sentinel events reported to the Commission in 2012/13, including seven wrong patient, site or procedure cases.
Mr Ian Civil,
Clinical Lead

18. Perioperative Harm Reportable Events

19. A few 2012/13 Serious Adverse Events
Bilateral brachial plexus injury as a result of positioning during surgery
Burn from chlorhexidine igniting
Air in bypass system resulting in cerebellar infarct
Wrong patient had cardiac procedure
Infected pacemaker sites (x3) due to inadequate skin-prep

20. Foreign body - results

21. Reducing perioperative harm
Effective interventions
Perioperative harm can be reduced by:
effective team work and communication strategies
effective use of all three parts of the World Health Organization (WHO) Surgical Safety Checklist
appropriate treatments against the formation of blood clots.

22. Lets talk about the Checklist
The WHO surgical safety checklist has a core set of safety checks that should be performed every time: sign in; time out; and sign out for every operation
Effective use of the checklist by DHBs in New Zealand is likely to lead to an estimated 21–36 percent reduction in avoidable complications from surgery
This could save the New Zealand health system $5.7 million per annum.

23. Attitudes to using the checklist in NZ
Lack of understanding of the overall intent & applicability
Not seen as a tool to support patient safety, teamwork and communication
Lack of clinical buy-in/engagement
Lack of local evidence of benefits
The sign-out phase is not implemented well
Discussions relating to anticipated critical events happen too late in the process
Checklist is complex with too many checks and perception of duplication with other checks

24. We Are Not as Good as We Think
If the DHB has done a culture survey it would be good to include their results to present local evidence.
We’re not quite as good as we think. There’s a discrepancy between what we surgeons think of ourselves and what the other people on our team think about us. This slide shows that you get very different results when you ask surgeons and OR Nurses to rate each other’s communication and teamwork abilities. 87% of the time the surgeons think the nurses are good teammates. But when you ask the nurses if they think the surgeons are good teammates, you get a very different picture. It’s this gap that we’d like to close. We’d like both of those bars to sit up near the top of the chart so that the surgeons and the people around them are in agreement that the teamwork on our ORs is really, really good.
Makary et al., J Am Coll Surg 2006; 202:

25. We are very good at what we do…. We can be even BETTER

26. Reducing perioperative harm
Reduce Perioperative Harm
Improve teamwork and communication
Use evidence based interventions
Use team briefings at the beginning of the list
Use the WHO surgical safety checklist for each patient
Use team debriefing at the end of the list
Appropriate use of VTE prophylaxis
Additional interventions as programme develops

27. HOW YOU ACT DURING THE CHECKLIST & BRIEFING MATTERS
Surgeons - the Team is looking to you for leadership.
You are setting the tone for the rest of the operation.
Others will follow your patterns of communication.
This is an opportunity to make your plan clear, answer questions, demonstrate openness and professionalism.

28. What Can You Do?
Activate people by using their names.
Set the Tone – Make everyone feel “safe”.
Tell the team what you are going to do.
Encourage team members to speak up.
Stop to Debrief at the end of the case.

29. Patient Safety Campaign
Perioperative Harm is the focus of the Open Patient safety campaign April – September 2014
April – the Case for Change
May – Surgical Safety Checklist
June – Briefing and Debriefing
July – Risk Assessment for VTE
August – VTE – appropriate prophylaxis
September – celebrating successes

30. How can you get involved?
Ask us questions
Participate in the campaign
Let us know what you would like covered in the campaign
Volunteer to be a champion for the programme
Talk to your colleagues about what we are trying to achieve

31. Thank you