Kupu Taurangi Hauora o Aotearoa

Quality and Safety are at the Heart of Clinical Practice

“First Do No Harm”

“To Err is Human” – Institute of Medicine Report USA (1999)

Peter Davis NZ (2002) – 12.9% medical error, though many minor

Australia (1995) - 16.6%

Britain (2001) - 10.8%

Key Questions• How can you tell you are delivering a quality

service, and a safe service?• What information do you use?• How does a “system” answer the same

questions?• How do you and/or the system change if you

need to?

Why has health quality and safety become an “industry”?

tools, methodologies, body of knowledge/evidence, training modules, monitoring etc

How can this become an automatic part of every day work for individuals and systems?

The Commission

• Formally established under the New Zealand Public Health and Disability Act 2000 in November 2010

• Crown Agency under the Crown Entities Act 2004• Has picked up many of the programmes of the

former Quality Improvement Committee

Our role (in legislation)

• Provide advice to the Minister of Health to drive improvement in quality and safety in health and disability services

• Lead and coordinate improvements in safety and quality in health care

• Identify data sets and key indicators to inform improvements in safety and quality

• Report publicly on the state of safety and quality, including performance against national indicators

• Disseminate knowledge on and advocating for safety and quality

Best value for publichealth system resources

QUALITY

IMPROVEMENT

The New Zealand Triple Aim

SYSTEM

We do need to do things right, first time

But we also need to do the right things

And only the right things

Doing the right thing

Overarching Focus :

Building an Improvement Culture

Key elements of quality

Information

QUALITY

IMPROVEMENT

1. Clinical leadership (underpinned by good management

infrastructure)

Support for training in tools, improvement methods and innovation, based on specific programmes or priorities

Support and maintain “networks”

2. Consumer engagement and participation

• Stock take of existing consumer organisations; • Develop and support a ‘national network’ of consumers;• Supporting and developing appropriate health literacy

3. Information

• National measures of quality and safety; • Report or “Atlas” of healthcare variation; • Quality “Accounts”• Sharing knowledge on quality and safety – e.g. active

website

“…success… …requires credible measurement. The measurements need not be of research quality, but they must be honest, obtainable with as little disruption and added cost as possible, consistent across hospitals so they can be analyzed in the aggregate, and transparent”

Also true in primary care and across primary and hospital care

Measurement

Berwick et al JAMA 2008

Measurement EffectsThe outcome of any recommended action to improve safety should be measured because:

• it may not be effective•‘revenge effects’ may occur.

Improving safety in an established and highly functioning health care system is not easy and the detail matters

The dimensions of quality and organisational layers of

healthcare

Runciman B Merry A Walton M Safety and Ethics In Healthcare Ashgate 2007

www.dartmouthatlas

Geographic variations in Medicare resource use across practice intensity

Dartmouth Health Care Atlas(John Wennberg)

Our initial focus

• Ensuring current programmes in public hospitals work

Next areas of focus (3 years) include:

Programmes extending to -• primary health• private providers• services for older people• maternity services• mental health services• people with disabilities• children and young people

Mortality Review Committees

• Child and Youth Mortality Review CommitteeDr Nick Baker

• Perinatal and Maternal Mortality Review Committee Prof Cynthia Farquhar• Family Violence Death Review Committee

Wendy Davis• Perioperative Mortality Review Committee

Prof Iain Martin

The Way We Work• Facilitate & support

implementation of projects/programmes in all parts of the sector

• Work with clinicians, other providers and consumers to assist with improvements and innovations that will make our health system safer

• Work in partnerships with other agencies – no duplication

• Draw on overseas experience and innovation, adapting it for New Zealand’s circumstances.

It’s about….…. supporting others to put in place systems and processes to ensure the safest and highest quality care

….supporting services to learn from mistakes so they don’t happen to others.

(reducing harm and variation)

Current work programme (to 2012)1. Medication Safety

Working towards the introduction of electronic prescribing, dispensing and monitoring of medication – firstly by:

– national introduction of standardised (initially adult) medication chart and reconciliation of medicines process

– demonstration sites of e-prescribing and e- medicine reconciliation

2. Reducing hospital-acquired infections(hand hygiene, IV line/catheter, surgical sites, etc)

3. Learning from other preventable adverse events (e.g. reducing falls)

4. Reviewing implementation of the surgical checklist

5. Reducing falls which cause harm

Surgical Site Infections (SSI)• Savings per SSI avoided estimated* at:

– $21,000 for knee & hip joint replacements– $20,000 for coronary artery bypass grafts– $4500 for caesareans

• A surveillance system could avoid 421 SSI each year• Total savings after first 10 years estimated at $18.8

million approx, and then $4.4 million a year ongoing

* Sapere Research Group publication, May 2011

CLAB Reduction Savings – one DHB

2008 2009 2010

Number of CLAB cases 14 4 1

Median days between CLAB cases

28.1 75.1 N/A

CLAB / 1000 line days 6.8 3.0 0.9

Cost of CLAB cases $280,000 $80,000 $20,000

Berwick et al JAMA 2008

• Obtaining the evidence• Evaluating the evidence• Promulgating the evidence• Persuading practitioners to

adopt the evidence and practice according to it, sustainably

Challenges to changing practice

Diffusion of knowledge and information

• Networks – local, regional, national and international

• Website and associated social media• Publications – journals, magazines• Media -- look for the opportunity

• Posters, hand-outs etc• Conferences, teaching sessions

What we don’t do• Handle individual consumer cases

or complaints (providers, HDC)• Enforce regulations or legislation

(MOH, HDC, registration bodies)• Quality assurance or compliance

auditing – e.g. for certification (MOH, registration bodies)

• Credentialing of individual clinicians (DHBs & other providers)

Our BoardProfessor Alan Merry (Chair), Head of Department for Anaesthesiology at the University of Auckland’s School of Medicine

Dr Peter Foley, Chief Medical Officer - Primary Care, Hawkes Bay DHB

Mrs Shelley Frost, Deputy Chair and Executive Director (Nursing) of General Practice New Zealand

Our BoardDr David Galler, intensive care specialist at Middlemore Hospital

Dr Peter Jansen, Senior Medical Advisor to ACC

Mr Geraint Martin, Chief Executive Officer of Counties Manukau DHB.

Mrs Anthea Penny, Director of R H Penny Ltd, Australasia

What do you think we should be doing?

• Contact us on: info@hqsc.govt.nz

• Our website: www.hqsc.org.nz – please register!