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Raising the Quality Bar in Health

20 February 2008


Raising the Quality Bar in Health

The New Zealand health system is raising the bar to improve its performance in quality and safety.

"New Zealand compares well with wealthier countries from the OECD on a range of indicators, including patient safety, timeliness and efficiency, says Director-General of Health Stephen McKernan.

“Sadly, there are instances where things go wrong and people are harmed or die. "Each preventable death is one too many. "While we can rationalise the statistics, we should never forget that we are talking about people and their families."

Mr McKernan says for many years health systems around the world have been actively encouraging health care workers and health systems to record and notify these events. System improvements come from understanding how the outcome could be avoided and what could be done differently in future.

"Where a serious event occurs, it is vital we learn from those events. "We need to understand what went wrong and why so that we can work to prevent a similar situation happening again. "At the same time, we have an ethical duty to talk openly about what happened.’’

“New Zealand hospitals are busy places. "Dedicated and hardworking doctors, nurses, midwives and other highly trained health workers care for thousands of people every day and the vast majority of people receive safe care.

"We also know that the public rates highly their experience of the health system. "It is the job of the Ministry of Health and district health boards to further build on that to enhance their trust and confidence in our hospital system", says Mr McKernan.

In New Zealand a Ministerially appointed Quality Improvement Committee was tasked with advising on where the sector should best place its emphasis to achieve quality and safety outcomes.

One of the committee's key tasks is to improve national systems for reporting incidents and standardise the classification of incidents around the country. Its work also includes infection prevention, safe medication management, improving the patient journey and national mortality review systems.

“The committee was set up in February last year and in August the Minister of Health approved $20 million towards five projects under the National Quality Improvement Programme. A considerable amount of work has already been done on the development of each of the projects.

The Ministry is taking a leadership role internationally. It is working with the OECD to establish internationally recognised measurements for safety. "We are one of the cosignatories to the World Health Organization's initiative on patient safety and health care quality launched in 2007. As well as learning from our own data we are keen to share our experience with the rest of the world and learn what we can from them and from shared initiatives.


Serious And Sentinel Events – Questions & Answers

What is the expected number of events?
International studies have shown that 10% - 15% of hospital admissions are associated with an adverse event, but half of these events occur prior to that hospitalisation in other healthcare settings such as GP clinics and private hospitals. Many of these are known complications of treatment and are not preventable with current knowledge. A small number are serious and preventable.

What is NZ’s level?
A study led by Professor Peter Davis of Auckland University, which reviewed hospital notes, found that 12.9% of public hospital admissions were associated with an adverse event. Half of these had occurred prior to the hospitalisation and most were not serious. Less than 0.2% of admissions were associated with a preventable adverse event which caused permanent disability or death.

The figures collated over the last month for the 06/07 financial year show that approximately 0.022% (2.2 in 10,000) of patients in hospital were reported as actually, or potentially seriously harmed or dieing in events that could have been prevented.

What is an acceptable level of risk?
Modern health care is complex and has high expectations. It uses powerful drugs and treats an increasingly elderly population with multiple illnesses. With all of this comes the increased risk of human error, which is why we are looking at ways to build in sophisticated systems for improving patient safety. Considering the large number of patients treated successfully every day, it is rare that a patient is harmed.

Other high risk industries, such as aviation are well ahead of healthcare in anticipating errors and building safer systems. Health care is still learning to apply the techniques and lessons from these other industries to investigate such events, learn from the causes and take steps to reduce risks in future.
All these industries accept that errors will occur, but work very hard to minimise both the number of errors and their impact– attention to safety is a fundamental part of all their operations. Part of this responsibility is the impartial investigation of the accidents that do occur so that additional defences can be put in place.

Why are you only releasing summaries?
We’re releasing all relevant information – what happened, what we learned and what we’ve done to try and prevent it happening again. Although some of these cases have been made public, patients, families and staff involved are entitled to, and deserve, privacy. The important thing is showing what hospitals have done to improve patient safety.

Why can’t we say the hospital with the most incidents is the least safe?
These are only the reported events that fall within the definition of serious and sentinel – not all events. The number of incidents is not an indicator of a hospital’s safety – a large number of incident reports is also a sign of a high safety focus amongst staff. Larger specialist hospitals will also have bigger numbers because they see more patients and deal with more complex cases. Reporting systems currently vary from hospital to hospital.

Are you saying some hospitals are underreporting these incidents?
Different reporting rates between hospitals are likely due to different approaches to how incidents are reported and recorded – the work we’re doing now, which is happening all over the world, is aimed at achieving a consistent approach so we can learn from good information.

Don’t you think people should be held accountable when things go wrong however it may make them feel?
They are. There are processes that hold clinical professionals accountable for the quality of their work and maintaining professional standards – those are separate processes. The reporting of these incidents is about looking at our systems and how we can improve them to minimise the risk to patients.

From a clinical perspective, blame is counter-productive: it decreases willingness to report and it does not engage institutions to design the safest possible system of care; it incorrectly assumes that individuals are solely responsible for errors. Removing an individual but not fixing an incorrect process will not prevent future errors.


The Quality Improvement Committee

The safety and quality of our health services is of high importance and has been the subject of significant investment of time and resources over the last 12 months.

In late 2006, a group appointed by the Minister reported on the highest priority quality improvement initiatives that could be actioned in New Zealand Hospitals.

In February 2007, the Quality Improvement Committee – QIC – was established to provide independent advice to Parliament to make and implement recommendations on national quality improvement.

The Quality Improvement Committee consulted widely and presented business cases on the five highest priority projects to the Minister. The projects included arrangements for leading and coordinating the work of District Health Boards and the Ministry of Health along with appropriate mechanisms for oversight.

Quality improvement is an integral part of health planning and the Quality Improvement Committee is leading the work to consolidate and build on the work that many DHBs have already been doing in this area.

In August, the Ministry of Health approved $20 million for components of the following five projects under the National Quality Improvement Programme:

Project / Lead DHB / Funding
Optimising the patient’s journey / Counties Manukau – Geraint Martin / $2m over 3 years
Management of Healthcare incidents / Waikato – Craig Climo / $1.15m over 2 years
Infection prevention and Control / Auckland – Garry Smith / $0.75m over 18 months
Safe Medication Management / West Coast – Kevin Hague
Hutt Valley – Chai Chuah / $10.2m over a multi-year period
National Mortality Review Systems / Joint DHB & Ministry of Health / $5.5m over 3 years

Additional change management costs will be met by DHBs. The work of the committee is building on the strong support commitment of DHBs and providing the opportunity to coordinate the efforts in this field and reduce the chance of duplication.

Committee Members

Patrick Snedden, Chair – Chair of Auckland DHB.
Prof Alan Merry – Professor of Anaesthesiology, University of Auckland and Chair of the Quality & Safety Committee of the World Fed of Societies of Anaesthesiologists.
Barbara Crawford – Quality and Clinical Risk Manager of Waikato DHB.
Barbara Greer – registered psychiatric nurse and member of the Health Advisory Group of the Maori Women’s Welfare League.
Catherine Rae – Quality and Risk Manager at Otago DHB and Chair of the National DHB Quality and Risk Managers Group
Prof. Cynthia Farquhar – Postgraduate Professor of Obstetrics and Gynaecology, University of Auckland and Deputy Clinical Director of Gynaecology at National Women's at Auckland City Hospital.
Dr Jean Hera – community health worker/manager of the Palmerston North Women’s Health Collective and a public member of the Medical Council of NZ.
Dr. Jim Vause – a GP since 1979, former President of the Royal NZ College of GPs and involved in GP quality initiatives nationally, workforce planning and evidence based guideline development with NZGG
Judi Strid – Director of Advocacy at the Office of the Health and Disability Commissioner to ensure close links on quality initiatives between QIC and HDC.
Kevin Hague – CEO West Coast DHB and representative of the country’s 21 DHB CEOs.
Dr Mary Seddon – Head of Quality Improvement, Medicine and Acute Care at Middlemore Hospital, and senior lecturer in quality improvement theory and techniques at the Auckland School of Population Health.
Dr Nick Baker – Paediatrician, Nelson Marlborough DHB and Chair of the National Child and Youth Mortality Review Committee.
Dr Robin Youngson – Anaesthetic specialist, former Clinical Leader at Waitakere Hospital and an inaugural member of the International Steering Committee on Patient Safety Solutions within the WHO Global Alliance on Patient Safety.


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