National Standards: a tool

for disruption to improve

patient safety and patient

centred care

19 May 2016

Naomi Poole

Program Manager, Partnerships with Consumers

About the Commission

• National government organisation

• Funded by Commonwealth and all states and territories

• Leading and improving safety and quality in health care

• National policy statements, guidelines, standards

• Development of the National Accreditation Scheme

• Strategic priorities are in the areas of:• patient safety

• partnering with patients, consumers and communities

• quality cost and value

• supporting health professionals to provide safe and high-quality care.

Outline

• What do the Commission mean by patient centred care

and partnerships?

• Why bother??

• What is the policy context?

• What are the NSQHS Standards?

• Small discussion – version 1

• Review of Standards

• Small discussion – version 2

• What’s next?

A confusion of terms

• patient / person / client / consumer (individual)

• community / citizen (collective)

• patient-centred care / patient and family-centred care /

consumer-centred care / patient based care

• partnerships with consumers and carers

• patient involvement / participation / engagement /

activation

A plethora of models

But what is it really?

You tell me….

Patient centred care and partnerships

• How it looks?

• patients are treated with dignity and respect

• information is shared

• patients are encouraged to participate and collaborate in their

own care to the extent that they choose

• What it means for the patient?

• the best quality care and best possible experience for the patient

• health care that suits the needs and preferences of the patient as

well as their clinical needs

The purpose of the partnership

To improve

the individual patient’s

care

To improve the care

for all patients

Partnerships between

patients and health

professionals

Partnerships between

consumers / communities and

health services

The evidence:

Patient-centred care and outcomes

• Evidence that patient-centred care is associated with improved safety and quality, lower costs, improved patient and provider satisfaction

• Evidence of benefits including:• decreased mortality

• improved care

• lower length of stay

• fewer medication errors

• lower infection rates

• fewer diagnostic tests and unnecessary referrals

• reduced costs

Predictors of one-year mortality

after AMI

Predictor Hazard ratio P value

Adherence to care guidelines 0.901 0.830

Patient-centred care 0.992 0.015

Access to providers 0.994 0.020

Courtesy 0.995 0.227

Information about care and illness 0.996 0.076

Coordination of care 0.992 0.008

Attention to patient experiences 0.993 0.004

Emotional support 0.996 0.074

Family involvement 0.997 0.179

Physical comfort 0.989 <0.001

Preparation for transition to outpatient 0.999 0.48

Meterko et al, Health Services Research, 2010

Relationship Between Patient Activation Measure

Levels And Health Outcomes Two Years Later

ODDS RATIO

PATIENT ACTIVATION LEVEL

1 (LOWEST) 2 3 (HIGHEST)

CLINICAL INDICATORS IN

NORMAL RANGE

Hemoglobin A1c (5,547) 0.92 0.79 0.85

High-density lipoprotein (14,106) 0.66 0.69 0.84

Low-density lipoprotein (14,531) 0.97 0.97 0.96

Serum triglycerides (14,058) 0.76 0.77 0.88

Systolic blood pressure (25,224) 1.03 0.91 0.93

Diastolic blood pressure (25,224) 0.94 0.96 0.96

PHQ-9* (7,294) 0.45 0.60 0.80

HEALTHY BEHAVIOURS Not a current smoker (25,522) 0.64 0.65 0.81

Not obese (25,358) 0.62 0.62 0.79

PREVENTIVE

SCREENINGS

Pap smear (14,848) 0.65 0.83 0.96

Mammography (8,180) 0.63 0.81 0.89

AVOIDANCE OF COSTLY

UTILISATION

No ED visits (32,060) 0.72 0.79 0.95

No hospitalisations (32,060) 0.79 0.86 0.98

Greene et al, Health Affairs, 2015

Patient participation and adverse events

Weingart et al, International Journal for Quality in Health Care, 2011

Participation activity Odds ratio

(95% confidence

interval)

Knew about the problem promoting admission 1.15 (0.67-1.98)

Felt well enough to talk with doctor/nurse 0.33 (0.20-0.53)

Found a doctor/nurse to tell you what you wanted to

know

0.50 (0.30-0.82)

Doctor/nurse described good/bad things about

treatment options

0.60 (0.39-0.94)

Participated in decisions 0.36 (0.20-0.65)

Visitor made sure wishes were followed 1.15 (0.74-1.79)

You checked your medicines 0.95 (0.65-1.40)

High participation overall 0.49 (0.31-0.78)

Staff experience and patient experience

Support

from

managers

Reporting

errors and

near

misses

Hand

washing

materials

available

Work extra

hours

Work-

related

stress

Violence

from

colleagues

Treated with

respect and dignity

Doctors talked in

front of you as if

you were not there

Nurses talked in

front of you as if

you were not there

Doctors and

nurses worked

together well

Doctors gave

answers you could

understand

Nurses gave

answers you could

understand

Raleigh et al, Quality and Safety in Health Care, 2009

At the organisational level:

design and governance

• Impact on service planning and development:

• design of new building and environment

• location of, and access to services

• provision of additional services and reorganisation of existing services

• methods of communication between consumers and clinicians

• peer groups and support groups for patients

• Impact on information development and dissemination:

• production of public and patient information

• raising awareness

• developing/contributing to training sessions

• Impact on attitudes of clinicians

Crawford et al, BMJ, 2002

Mockford et al, International Journal for Quality in Health Care, 2011

Where’s the action? How do you drive

change?

International policy frameworks

• Declaration of Alma Ata – 1978:

“The people have the right and duty to participate individually and

collectively in the planning and implementation of their health

care”

• United States – 2001 Institute of Medicine report:

• dimensions of quality: safe, effective, patient-centred, timely,

efficient, equitable

• United Kingdom – 2013 Quality in the new NHS:

• legislated definition of quality that comprises patient safety,

clinical effectiveness, patient experience

National policy framework

• Australian Charter of Healthcare Rights (2008)

• Australian Safety and Quality Framework for Health

Care (2009)

• National Primary Health Care Strategic Framework

(2010)

• Ten-year Road Map for National Mental Health

Reform (2012)

• National Safety and Quality Health Service

Standards (2013)

• National Disability Insurance Scheme (2013)

• Blueprint for Mental Health Services (2015)

The National Safety and Quality

Health Service Standards

What are the Standards?

• Aim: Provide a nationally consistent statement about the

level of care consumers can expect from health service

organisations.

• Developed over 5 years

• Considerable stakeholder engagement and consultation

• Approved by Ministers in 2011

• Mandatory for Australian health services to be

accredited against the NSQHS Standards from 2013

The ten Standards (v1)

Standard 2: Partnering with Consumers

(v1)

• Focused on partnerships with consumers in governance

• First time partnerships/patient centred care was part of

accreditation requirements

• Based on international evidence and models for patient

centred care

• Organisations starting from variable baselines

Structure of Standard 2 (v1)

2.1.1 2.1.2

Governance

and policy

framework

Training

2.6.2 Consumers

involved in training the

workforce

2.6.1 Training for the

workforce

2.3.1 Training for

consumers partnering

with the organisation

Partnering with

consumers for

improvement

2.2.1 Partnerships in

strategic and

operation planning

2.2.2 Partnerships in

decision making about

safety and quality

2.5.1 Partnerships in the

design and redesign of

health services2.8.1, 2.8.2 Partnerships in the

review of organisational safety

and quality performance and

development of improvements

2.9.1, 2.9.2 Partnerships in

the review of patient feedback

data and development of

improvements

Information

2.7.1 Information about

safety and quality

performance provided to

consumers and the

community

2.4.1, 2.4.2 Feedback from

consumers about patient

information publications

included in final

publications

Small group work (15 mins)

Introduce yourself - talk to the table about your role

Are you involved in accreditation?

What are the challenges you’ve faced?

What are the opportunities?

Who do you need to engage?

How would you measure success?

Reviewing Standard 2

Challenges

• Can be seen as hard to implement (no single approach)

• Resourcing a barrier

• Leadership and engagement

Positives

• Consumer participation seen to positively influence:

• service communications

• design, planning and governance

• delivery of person-centred services.

• Consumers can act as advocates for the health service

Reported challenges with implementing

Standard 2: how would you address them?

• Executive and management support and leadership

• ‘The Board are not really interested and we might have trouble finding someone who wants to be bothered’

• Policy framework for partnering with consumers

• ‘Formal processes didn’t exist. We needed to develop these up from scratch. Again, another significant project’

• Engaging consumers in partnerships

• ‘We attract [the] same people, need to change the way we do this as the voiceless and disengaged always miss out’

• ‘Most of our consumers are elderly and are not interested in being involved in any way with how the facility is run’

Reported challenges with Standard 2: how

would you address them?

• Involving consumers in governance

• ‘As an organisation that has major corporate fiduciary

responsibilities it is not appropriate to delegate some governance

responsibilities so the challenge is finding what governance can

be shared etc, so that consumers aren’t expected to be involved

in something, provide advice or input that an organisation can

never act upon if it is to be ultimately responsible, and therefore

not engage in non-authentic tokenism towards consumers’

• ‘Due to multi-layered governance model at work, there have been

few opportunities for consumers to be involved’

How the NSQHS Standards have

influenced consumer participation

• Support flexibility in approach

• ‘We are trying to frame them in a way that they are positive and

constructive…You can put your local identity and flavour to them.

And that’s what’s exciting about them.’

• Support a sense of urgency

• ‘It gives that impetus that ‘we should be doing this’, and kind of

brings everything together in a kind of structure.’

• ‘The standards made consumer participation as important as

medication, as important as clinical handover, and that’s really

helped.’

How the NSQHS Standards have

influenced consumer participation

• Accreditation drives continued change• ‘Getting a good accreditation score gave everyone a pat on the

back and people saw that they were making progress.’

• ‘You know the way, it is often getting to the finish line and then once we got to the finish line, after we collapsed.’

• Legitimised work to partner with consumers• ‘It gave us permission to do things that a lot of us had wanted to

do beforehand but hadn’t really been able to get the traction to do.’

• Provide a focus to identify gaps and opportunities• ‘The standards have provided a backdrop for the health service to

develop amore robust framework and consolidate its work.’

Reviewing the whole NSQHS Standards

Version 2 currently in draft

• One new standard

• Comprehensive care

• Three standards removed:

• Patient identification and procedure matching Communicating for

safety

• Pressure injuries & Falls Comprehensive care

Partnering with consumers standard v2

• Intent:• Create an organisation where consumers are partners in:

– planning, design, delivery, measurement and evaluation of systems and services

– their own care, to the extent that they choose

• Criteria:1. Governance systems

2. Partnering with consumers in their own care

3. Health literacy

4. Partnering with consumers in organisational design and governance

Partnering with consumers standard v2

• New focus on clinicians and consumers partnering at the

level of clinical care

• New actions around shared decision making,

assessment of capacity and identification of substitute

decision makers

• Health literacy focusses on communication that supports

effective partnerships – not just written information

Small group work (15 mins)

What would be the reaction in your service or organisation?

What changes would you need to make?

Who would you need to involve?

How would you measure success?

Next steps with the NSQHS Standards

• Another consultation process – focussing on

costs/benefits

• Starting preparation of safety and quality improvement

guide and other resources – there will be an opportunity

to provide input before they are finalised

What else is going on?

• Ongoing work about health literacy:

• resources for organisations, particularly in the context of the new

NSQHS Standards

• scoping work about standards for health information

• Partners for safety

• online question builder

• review of 10 Tips for Safer Care

• Shared decision making

• online risk communication module

• developing patient decision aids

• Person-centred healthcare systems

• What does a person-centred healthcare system look like?

• How do we achieve the change that is needed?

Summary

• Although Standard 2 has been challenging to implement, we are seeing

improvements

• The scope of the Partnering with Consumers Standard in Version 2 is

broader

• Version 2 will probably not be mandated for accreditation until 2018/19

• Work also going in shared decision making, health literacy, supporting

consumers to be involved in their own safety

• Discussion paper later this year re the person-centred healthcare

system

www.safetyandquality.gov.au

Naomi.Poole@safetyandquality.gov.au