1. Lessons from the Inquiry into the King Edward Memorial Hospital Obstetrics and Gynaecological Services Presentation to Womens Hospitals Australasia/ Childrens Hospitals Australasia National Conference, Perth, 10 April 2001 by Dr Michael Walsh, Deputy Chair, Australian Council for Safety and Quality in Health Care

2. Why is ACS&QHC Interested? Make the findings of the Inquiry more accessible and relevant Identify lessons and opportunities for system change Identify lessons and opportunities for operational management and governance change Work cooperatively with stakeholders (KEMH, HDWA, WHA/CHA)

3. Overview of Discussion Review of Inquiry and Findings Lessons for Health Care Institutions: ä operational/clinical management ä governance Lessons for System and Policy-makers

4. King Edward Profile WA’s only tertiary referral services for obstetrics and gynaecology 250 inpatient beds, neonatal intensive care, outpatients and specialist emergency services 5,000 births per year 5,000 gynaecology operations 8,000-10,000 emergency presentations High and increasing case complexity

5. Lead-up to Inquiry Significant change and upheaval including: merger with children’s hospital two new chief executives; devolved management focus of MHSB taskforce to review WA O&G steering group reviewed recommendations independent review by retired clinician Child and Glover review strong public debate about future of KEMH

6. Inquiry’s Brief Established under Hospitals and Health Services Act Examine management and clinical practices, policies and processes from 1990 to 2000 Focus to “identify and assess the deficiencies” (1) Recommend changes to improve short- comings 1.Executive Summary, Inquiry into KEMH 1990 to 2000, Final Report, Vol.1, November 2001

7. Method Extended over 18 Months Accessed information from 1600 patient files Analyzed 605 patient files Analyzed ninety-six medico-legal cases Compared KEMH clinical performance data with 13 similar Australian services (Consortium) Reviewed 293 written submissions Interviewed 70 former KEMH patients Read 106 transcripts, reports & other documents Resource intensive (expensive)

8. General Observations regarding Inquiry Report Very long and difficult to access Language of system failure; reality of great detail and “naming names”. Was the Inquiry welcomed? Readership? ä Minister/Government? ä Institutional Governance? ä Management/Staff? ä Patients/General Public ä All of the above?

9. Limitations Inquiry Approach ä negative bias; adversarial ä lengthy; expensive Prone to political influence; Focus on high-risk cases; Non-representative sampling; Limited inter-hospital comparison;

10. Strengths Level of detail of review Case studies for learning/teaching purposes Focus on clinical practice issues not usually talked about: ä standards of care ä responsibility and accountability ä supervision of juniors ä credentialling and training Discussion of management responsibilities for safe care

11. Findings - Strengths Many examples of exemplary care & service Concerted effort by some to address or improve long-standing problems

12. Findings - Management Management failed to: make & act on important decisions create an open, transparent, positive culture monitor & improve safety & quality clarify accountability, responsibility & reporting ensure staff were properly trained/supervised address serious clinical issues adversely affecting care & clinical outcomes

13. Findings - Senior Doctors Insufficient involvement in complex cases Inadequate, delayed or absent decisions Inadequate credentialing, appointment, re- appointment, admitting privileges processes Inadequate performance management Inadequate supervision/training of juniors Failed to provide timely, detailed analysis of staffing needs

14. Findings - Junior Doctors Left to do much of the complex work Unreasonably burdened with difficult cases Inadequately supervised/supported Requests for help often delayed or ignored Blamed for errors - “sink or swim” Inadequate orientation & training Supported more by midwives than senior doctors

15. Findings - Clinical Practice Ineffective or absent: care planning, coordination, documentation policies & practices based on best evidence Poor management of: complex & emergency cases women needing intensive care services incidents & adverse events Poor clinical & emotional outcomes for women & families

16. Findings: Clinical Review & Reporting Inconsistencies in: review and report of deaths to the Coroner report, review and response to incidents & adverse events management of complaints and medico- legal cases review & compare clinical performance & respond to performance issues

17. Findings - Internal Policies and Processes Absent or inadequate: quality improvement program incident/adverse event monitoring & follow- up complaints & medico-legal case management committee functioning & review policy development, deployment, review recruitment, employment, performance management, training

18. Findings - Women & Families Often excluded from decisions about care Concerns ignored or overlooked Treated poorly as complainants Given untimely and inadequate information, particularly when things went wrong Rarely involved in policy decisions

19. Comparison with Bristol Heart surgery on babies in Britain’s Bristol Infirmary from 1988 to 1994 Deaths following arterial switch operation Excessive time take to do procedure Concerns raised repeatedly by an anaesthetist Senior doctors and chief executive eventually faced prosecution

20. Common Themes In both cases, management’s failed to: respond to important issues raised repeatedly ensure clinicians were properly trained build a culture of transparency/open disclosure establish effective quality systems give patients & families adequate information about risks, care & problems with care effectively manage complaints/medico-legal cases

21. Lessons for Institutional Management and Governance 1. Leadership & Culture 2. Accountability & Responsibility 3. Safety & Quality Systems 4. Staff Support & Development 5. Concern for Consumer & Families

22. System Issues Institutional Governance Role of Board, Management in Patient Safety Importance of Benchmarking and Comparative Data Importance of Incident Monitoring, Reporting, Management and Review Importance of Mortality Review Importance of Periodic External Review of Management Policies, Procedures and Practices

23. System System Issues System Governance Role of Regulatory/Statutory Authorities ä Mortality Committees; ä Coroner Role and Function of External Accreditation ä Standards of practice (incl credentialling) Role and Structure of “Special Inquiries” Importance of Comparative Data ä voluntary versus mandatory ä clinical privilege (Immunity) ä public disclosure

24. Conclusions Inquiry is a landmark in the evolution of health care safety and quality policy and practice in Australian hospitals; ACS&QHC Summary and Implications document should be required reading for all hospital managers and Boards We should learn from the Inquiry findings and limitations to develop better ways of monitoring and reporting safe patient care environments.