ACHSE 48th Residential ConferenceMarch 2002

Leadership and the Quality Challenge - the National

PerspectiveHeather Wellington

Member, Australian Council for Safety & Quality in Health Care

Current Context of Health Care

• expanding health wants

• limited resources

• cost containment

• greater clinical accountability

• expanding technology and demographic changes

• workforce pressures

Health System Activity

• 19 million people

• 209.566 million Medicare services (1999/2000)

• 5,563,074 hospital separations (in 1997-98)

• day surgery increase from 7% (1980) to 55%

• high doctor / population ratio

• very high bed usage

Economic Improvement

• we are doing more with less

• expenditure all health services

7.5% (1985/86) - 8.4% (1997/98) of G.D.P.

• number of services increased by 30%

• productivity savings (anaesthesia and surgery)$4 billion/year over 20 years

(Access Economics)

Adverse Event

• an incident in which harm resulted to a person receiving health care

• may include: complications of diagnosis or treatment misadventure mistakes - slips and lapses errors - latent, active, omission,

commission, systems, individual

Adverse Events

• 10% of admissions associated with adverse events

• 50% of adverse events are severe

• 50% are preventable

• most common adverse events: wound infection adverse drug events falls and pressure sores

Unsafe Care is Costly

• inappropriate use of drugs results in 80,000 admissions / year and costs $350 million

• adverse drug events – 10-20% of all adverse events

• ten years wrong side / wrong site surgery = one day’s adverse drug events

• total cost of unsafe care $1 – 2 billion /year

The Safety Message

Safety is the most important dimension of quality for patients and their families

“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

The Safety Message

• the health system delivers safe care for the majority of patients

• the challenge is to move from 90% reliability to 100%

• everyone can focus on safety

Complexity a Major Hazard

• 25 component system that functions properly 99% of the time

• probability of whole system functioning perfectly is 78%

• with 50 elements, 61%

Many Competing Priorities

“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)

Accident Enquiries Suggest

• bad events more likely the result of error prone situations rather than error prone people

• the best people can make the worst errors

Organisational Accidents

“Error prone people do exist but seldom remain at the hazardous, sharp end for very long. Quite often, they get promoted to management!”

James Reason

Systems Focus Essential

• currently focus on the individual rather than the system

• medical culture personalises error

• the public, the media and the courts perpetuate the focus on the individual

Systems Focus Essential

• individual integrity and competence are important, but an emphasis on systems improvement is is critical

Where We Need to do Better

• identify and manage risks - knowledge based

improvement

• design for safety - reduce complexity

• encourage and reward improvement and innovation

• teams not individuals

• greater openness in: - assessing performance and outcomes- dealing with mishaps and system failures

Council’s Role

Council’s Role is to lead and co-ordinate 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.

Making Change Happen

• setting a national agenda for change – “the National Action Plan”

• building ownership through collaboration links and working parties

• developing and strengthening national standards

support for implementation

• tools for frontline clinicians and managers

• promoting the patient’s role in safety

Integrated Risk Management

Improved accreditation

Safe Patient Care

Health Care Acquired Infection

National Standards forIncident Monitoring

National Standards for Credentialling

Qualified PrivilegeReformed

Open Disclosurein place

Improved Medication Safety

Reduced Patient Falls

Health Care Safety Net Core Standards in Key Areas

Review and Action on Patient Deaths

Alerts from Trends in Coronial Data

Education, Systems Safety

Human Factors, Communication

States & TerritoriesInvolved

National Audits, Registers andBenchmarks

International Lessons Learnt

Specialist Vocational Registers

Glossary of Safety Terms

Consumer Needs Understood

Safety Innovations in Practice Programme

• to encourage innovation and excellence in practice

• value – up to $10,000 / project

• new projects

• not clinical research

Safety Innovations in Practice Programme

• Projects: 65 funded from 225 applications, $564,000

• Examples ACT better utilisation of interpreter services NSW reducing over-sedation in endoscopy

patients NT systems approach to medication error QLD automated computerised discharge advice

sheets SA changing hand washing behaviour VIC communicating for calm, reducing

aggressive behaviour WA evaluation and redesign of nursing

assessments and care planning documentation

Medication Safety Taskforce

• 2nd National Report on Patient Safety focused on medication safety

• Medication Safety Collaborative $5 million – tenders closed 11.2.2002

• high risk drugs identified actions planned

• workshop early 2002 I.T. support and electronic prescribing –

nationally compatible systems

What Do We Want From Our Medication Safety Programme?

• reduced harm by focusing surveillance analysis and action on harm not errors

• provide tools for doctors, nurses, pharmacists and other clinicians to improve safety

• redesign systems of prescribing dispensing delivery

• increase patient knowledge and involvement

Open Disclosure Initiative

• $450,000 tender awarded December 2001

• key deliverables conduct a review of legal issues develop national standards provide education and organisational support

packages

• completion date 2002

Open Disclosure Standards

• candour

• openness

• transparency

• cautious information sharing

• factual uncertainty

• high emotion

• legitimate legal interest

Need to balance stakeholders interests

Vs

Sentinel Event & Incident Monitoring

• nationally consistent specifications

• collaborative discussion across states lists of sentinel events reporting / analysis systems implementation of preventative action

• sentinel event criteria for inclusion causes serious harm indicates likely systems failure has capacity to undermine public confidence clearly identifiable

Conferences and Surveys

• Nov. 2000: 5th Australian Aviation Psychology Seminar

• April 2001: Survey of Health Care Professionals

• May 2001: with Consumer Focus Collaboration

National Consumer Consultative Conference and Workshop

• Sept. 2000: 1st Asia Pacific Forum on Quality Improvement in Health Care

System-wide Changes to Structures and Processes

• accreditation – core standards / risk management

• credentialling – includes performance review

• registration – specialist / vocational, requires C.P.D. and revalidation

• qualified privilege – reporting

• National Implantable Device Register

System-wide Changes to Structures and Processes

• curriculum development and educational strategies on systems safety, human factors and communication

• enhanced national morbidity and mortality data sets includes coronial reports

• national audits in priority areas to provide benchmarks

Opportunities from the Safety Agenda

• better structures

• more support

• a chance to fix problems we have already recognised

• better use of physical and financial resources

• clinicians involved in: setting the health agenda creating the future system

What Will Success Look Like?

• patient centred safety and quality values are paramount

• leaders are identified and nurtured

• systems are being continuously redesigned for improvement

• tools to make the necessary changes are available

• measurable improvement in safety and quality

www.safetyandquality.org