Clinical Governance: What is it What does it mean for Divisions

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Clinical Governance What is it?What does it
mean for Divisions!

• General Practice NSW Prof Cliff Hughes
• Sydney 1st April 2009

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Focus!
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Science!
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Science!
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Science!
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Accommodating Mistakes?

• I cdnuolt blveiee taht I cluod aulaclty
  uesdnatnrd waht I was redanig. The
• phaonmneal pweor of the hmuan mnid.  Aoccdrnig to
  rscheearch at Cmabrigde
• Uinervtisy, itd eosn't mttaer in waht oredr the
  ltteers in a wrod are, the
• olny iprmoatnt tihng is taht the frist and lsat
  ltteer be in the rghit
• pclae. The rset can be a taotl mses and you can
  sitll raed it wouthit a
• porbelm. Tihs is bcuseae the huamn mnid deos not
  raed ervey lteter by
• istlef, but the wrod as a wlohe. Amzanig huh?
  yaeh and I awlyas thought
• slpeling was ipmorantt!

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The First Wave Find the Culprit!Railway
Department Officers Report 1842

• Class 1 (Beyond the control of passengers)
• -29 accidents, 24 killed, 72 injured
• Class 2 (own negligence or misconduct)
• 36, 17 20
• Class 3 (Servants of the company)
• 60, 20 36
• note this return is incomplete, no requirement
  to report accidents which are not of a public
  nature

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Lucian Leape

• The greatest single impediment to error
  prevention is that

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Lucian Leape

• The greatest single impediment to error
  prevention is that
• We punish people for making mistakes.

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Disciplinary Theory

• Outcome-based Disciplinary Decision-Making No
  effect on intent?
• Rule-Based Disciplinary decision-Making Not all
  violations are bad
• Risk-Based Disciplinary Decision-Making Recklessn
  ess and negligence
• David Marx in Patient Safety and the Just
  Culture A Primer for Health Care Executives
  April 2001

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The Second Wave!

• October 12 1997 United States Congress
• House committee on Veterans Affairs
• Lucian L. Leape MD
• 1 million people injured each year
• 120,000 deaths
• 33 billion price tag
• 2 to 3 of major errors reported

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Mission

• To build confidence in health care by making it
  demonstrably better and safer for patients and a
  more rewarding workplace

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Mission

• To build confidence in health care by making it
  demonstrably better and safer for patients and a
  more rewarding workplace
• 1. the focal plane is our patients

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Mission

• To build confidence in health care by making it
  demonstrably better and safer for patients and a
  more rewarding workplace
• 1. the focal plane is our patients
• 2. the focal plane is our staff

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Mission

• To build confidence in health care by making it
  demonstrably better and safer for patients and a
  more rewarding workplace
• 1. the focal plane is our patients
• 2. the focal plane is our staff BUT
• 3. the lens through which we look is the system!

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Quality in context

• 1.25 million admissions
• 12 million outpatient services
• 57,808 incidents reported
• 289 SAC1 incidents (0.5)reported
• Figures from the Patient Safety and Clinical
  Quality Program Report released July 2008,
  figures relate to July December 2007

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The Role of the CEC

• To promote best practice systems for clinical
  quality and patient safety.
• To support Area Health Services in the
  implementation of their clinical systems
• To monitor the state of clinical quality and
  patient safety in the NSW Health system
• To provide education and training for clinicians,
  consumers and health managers on the
  implementation of clinical quality systems
• To provide advice to the Minister on matters
  relating to clinical quality and patient safety.

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Patient Safety and Clinical Quality Program

• Openness about failures
• Emphasis on learning
• Obligation to act
• Accountability
• Just Culture
• Appropriate prioritisation of action
• Teamwork and information sharing

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Key Drivers Values

• Excellence
• Quality
• Safety
• Authority

• Effectiveness
• Courage
• Transparency
• Integrity

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What makes CEC different?

• Reports directly to Minister
• Focused on the system
• Mandate to educate, support and monitor
• System-level interventions

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It is more difficult than it seems!
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1.Data or Information?

• Information management
• Data linkages
• Chart book
• Mud maps
• Data mining
• Signals vs. noise
• Predictive modeling

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1a. Safety

• A Particular focus!
• Incident Information Management System (IIMS)
• Reportable Incident Brief (RIB)
• Severity Assessment Code (SAC)
• Root Cause Analysis
• Mortality Reviews

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1b. IIMS

• Feed back the information from the data
• February 2006 State wide and Area Health Service
  
• To Chief Executives
• To Clinical Governance Units
• Facility and Clinical Service
• Individual Clinician

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2. Clinical Practice Improvement

• Improving Patient Access to Acute Care Services
• Towards a Safer Culture TASC On-Line
• Childrens Emergency Care Project
• Safer Systems Saving Lives (NSW)
• Clean Hands Save Lives
• The Blood Project

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3. Organizational Development and Education

• (read Clinical leadership)
• Responsibility
• Accountability
• Availability
• Skills
• Resources
• Recognition

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4. Quality Systems Assessments

• BAS and QSAS
• Self Lodgment
• MYOB and As you Go reporting
• Self regulating
• Targeted and informed audits

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5. System Reviews

• Meningococcal review
• Under reporting of surgical mortality
• Pacemaker morbidity
• Communications
• Open Disclosure Evaluation
• ADHD

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CEC and the Area Health Services?

• Focus
• Evidence and collaboratives drive the way forward
• Power and influence
• Integrated and disciplined approach for the
  system
• Experience and a knowledge base
• Willingness to challenge status quo
• Strategic staff placements

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CEC and Primary Care?

• Hand Hygiene
• Falls Program
• Medication safety
• VTE prevention
• Transfusion practice
• IIMS
• Clinical Guidelines
• Patient Safety Officers

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Patient Centred Care
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Patient Centred Care
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Patient Based Care
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Patient Based Care
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Patient Based Care
Listening
serving
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Patient Based Care
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Patient Based Care
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Vision!

• So I am called eccentric for saying in public
  that Hospitals, if they wish to be sure of
  improvement,
• Must find out what their results are.
• Must analyse their results, to find their strong
  and weak points.
• Must compare their results with those of other
  hospitals
• Must welcome publicity not only of their
  successes, but for their errors.
• Such opinions will not be eccentric a few years
  hence
• Ernest Amory Codman, 1917 ( 1869-1940,
  Surgeon, USA)

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Thanks for listening!

• Clinical Governance fascinating or awesome?

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Where can you find us?

• Website http//www.cec.health.nsw.gov.au
• Email Clifford.Hughes_at_cec.health.nsw.gov.au
• Address LEVEL 3, 65 Martin Place
• Sydney 2000
• Phone [phone]
• Fax [phone]