Transcript Leadership and the Quality Challenge

ACHSE 48th Residential Conference
March 2002
Leadership and the Quality
Challenge - the National
Perspective
Heather 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
 errors
- slips and lapses
- 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 coordinate 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
Health Care Safety Net
Core Standards in Key Areas
National Audits,
Registers and
Benchmarks
Reduced
Patient Falls
Review and Action
on Patient Deaths
Health Care
Acquired Infection
Open Disclosure
in place
Improved
Medication Safety
States & Territories
Involved
Education,
Systems Safety
Human Factors,
Communication
National Standards for
Incident Monitoring
International
Lessons Learnt
Integrated Risk
Management
Qualified Privilege
Reformed
Safe Patient Care
Improved accreditation
Glossary of
Safety Terms
National Standards
for Credentialling
Alerts from Trends
in Coronial Data
Consumer Needs
Understood
Specialist
Vocational Registers
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
 SA
changing hand washing behaviour
 VIC
communicating for calm, reducing
aggressive behaviour
 WA
evaluation and redesign of nursing
assessments and care planning
documentation
sheets
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
Need to balance stakeholders interests
• candour
• openness
• transparency
Vs
• cautious information
sharing
• factual uncertainty
• high emotion
• legitimate legal
interest
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