The place of mortality review within the

Health Quality & Safety Commission

Alan Merry

Disclosure and Acknowledgement

Dr Merry has financial interests in

Safer Sleep LLC

is on the boards of

NZ Health Quality & Safety Commission, ANZCA and Lifebox

and gratefully acknowledges support for research and/or travel from

ANZCA, HRC, AMRF, WHO, AFT, F&P Healthcare and others

Today….

1. The economy and other adverse events

2. Elements of quality 3. The Commission 4. Measurement 5. Conclusions

Harvard Medical Practice Study Quality in Australian Health Care Study

Medical Injuries Utah and Colorado NZ Quality in Healthcare Study

Case notes (completeness)

Subjectivity & definition Retrospective Outcome Bias

AEs common in hospitals, often from substandard care

NZ Serious Adverse Events 2013 – 2014

558 people in serious adverse events

454 from DHBs

52 from other providers

248 serious harm from falls

98 # NOF

158 clinical management events

30 medication events

73 deaths

Survey of 227 patients who had begun litigation against doctors:

“We wanted somebody to be brought to account”

Why do people sue doctors?

Vincent et al 1994 Lancet 343: 1609 - 13

Culpability

of

act

Seriousness

of

consequences

Improve safety and quality

Objectives

Established Nov 2010 - to lead and co-ordinate work across the health and disability sector to

(a) monitor and

(b) help providers improve

the quality and safety of health and disability services

http://www.hqsc.govt.nz/

Measurement

• Proportionate burden of measurement (cost and time) • Clear reason for measuring – to drive

– Improved processes and thus… – Improved patient outcomes – Reduced patient harm – Reduced costs

• Must make sense to the people doing the measurement and be reliable

Measurement should drive improvement

The New Zealand Triple

Aim

Influence by HQSC

Outcomes framework

Measurement

• Health Quality and Safety Indicators • Quality and Safety Markers

– process and outcome

• Variation • Events • Mortality • Patient experience indicators

Measurement should drive improvement

Quality accounts

State of the nation

report

http://www.scts.org/

• Child and Youth – 2002

• Perinatal and Maternal – 2005

• Family Violence Death – 2008

• Perioperative – 2010

The mortality review committees

Suicide age-standardised rates for OECD countries, males 15–24 years (WHO)

• An independent committee to advise the Commission on how to reduce the number of suicide deaths in NZ

• Established between the Ministry of Health and the Commission to trial a suicide mortality review mechanism

• Time-limited: April 2014 to September 2015

• Focus is to advise the Commission on how to reduce New Zealand suicide deaths.

http://www.hqsc.govt.nz/our-programmes/mrc/sumrc/about-us/

Doing things right

“The real problem isn’t how to stop bad doctors from harming, even killing their patients. It’s how to prevent good doctors

from doing so.”

Atul Gawande 1999 The New Yorker