ACHSE 48th Residential Conference March 2002

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ACHSE 48th Residential ConferenceMarch 2002

• Leadership and the Quality Challenge - the
  National Perspective
• Heather Wellington
• Member, Australian Council for Safety Quality
  in Health Care

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Current Context of Health Care

• expanding health wants
• limited resources
• cost containment
• greater clinical accountability
• expanding technology and demographic changes
• workforce pressures

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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

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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)

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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

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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

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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
  days adverse drug events
• total cost of unsafe care 1 2 billion /year

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The Safety Message

• Safety is the most important dimension of quality
  for patients and their families
• Consumers arent interested in your journey to
  quality. They want safe hospitals, they dont
  want to meet you at the beginning of your
  journey.
• Consumer Advocate

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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

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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

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Many Competing Priorities

• You ponce in here expecting to be waited on hand
  and foot, well, Im 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, youre
  all too busy sticking your noses into every
  corner, poking around for things to complain
  about, arent you?
• Basil Fawlty (aka John Cleese)

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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

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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

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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

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Systems Focus Essential

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

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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

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Councils Role

• Councils 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.

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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 patients role in safety

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Health Care Safety Net Core Standards in Key
Areas
Review and Action on Patient Deaths
Reduced Patient Falls
Health Care Acquired Infection
National Audits, Registers and Benchmarks
Open Disclosure in place
International Lessons Learnt
Integrated Risk Management Improved
accreditation
Improved Medication Safety
Qualified Privilege Reformed
States Territories Involved
Safe Patient Care
Glossary of Safety Terms
Education, Systems Safety Human Factors,
Communication
National Standards for Credentialling
Consumer Needs Understood
Alerts from Trends in Coronial Data
National Standards for Incident Monitoring
Specialist Vocational Registers
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Safety Innovations in Practice Programme

• to encourage innovation and excellence in
  practice
• value up to 10,000 / project
• new projects
• not clinical research

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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

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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

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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

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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

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Open Disclosure Standards
Need to balance stakeholders interests

• candour
• openness
• transparency

• cautious information sharing
• factual uncertainty
• high emotion
• legitimate legal interest

Vs
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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

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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

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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

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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

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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

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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

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• www.safetyandquality.org