Stephen Duckett’s report highlights need for new thinking on clinical governance

Background

The recently released Duckett Report was commissioned in response to a review of the role of DHHS in detecting and managing critical safety risks and clinical governance across the system following a cluster of perinatal deaths at Djerriwarrh Health Service in 2013-14.

 

The report highlights that while Victorians have a right to assume that healthcare is generally of a high quality across the system, there continue to be significant deficiencies in the system’s defenses against avoidable patient injury.

 

The report cites a 2014-15 review of hospital acquired diagnoses in Victorian Healthcare System, which concluded that “complications of care are far from rare in our hospitals”.  In fact, more than 300,000 patients per year suffer a complication in Victorian hospitals, at least 70,000 of which are potentially preventable such as malnutrition or pressure ulcers. Many of these result in fatalities.

 

This issue, to say the least, is huge.

 

The Duckett report was commissioned to review the role of the DHHS in preventing these events.

 

Essentially, the report calls for the department to better support Victorian Health Services in providing a high level of local clinical governance on safety and quality, to monitor outcome data more closely, and to respond more effectively when things go wrong.

Major Findings

To this end, the report makes several important recommendations, among them :

 

  1. The department must set a clear example to the wider health service that this issue is its number one priority
  2. The system should focus less on “meeting accreditation standards”, and instead greater emphasis placed on outcome monitoring
  3. The department better supports the boards of health services by reviewing the appointment and training processes for board members, to ensure they can effectively oversee hospital governance
  4. Performance of the health service is more effectively monitored, by making better use of available data and filling in gaps as they exist
  5. Improvements are made in the utilization of data, so that the entire system can benefit, and learnings are better shared
  6. All hospitals should be open to periodic external review
  7. That hospitals are held to account in only providing care that falls within its scope of capability
  8. Consumers and front line clinicians must have a louder voice in the quality assurance process.

 

What does this all mean?

Promoting a culture of transparency and accountability, and most importantly trust, are an excellent start, and to this end, the department is to be congratulated for the example it has set.

 

As Dr Duckett himself points out, the department acted immediately to support Djerriwarrh protect its patients, investigate the cluster of deaths and engage in an open disclosure process.  It then sought prompt external review of its own role in the process and made those results public immediately.  It is a high level demonstration of the transparent accountability required at clinician level.

 

The recommendations of the Duckett review create a better environment for patient safety across the wider health system but this is only half the battle. Left unanswered is how health systems prevent patient injury in the first place.  Albeit beyond the scope of the review, here lies the rump of the improvement curve – what are the hospitals and health services, their clinical managers and individual clinicians supposed to do to improve patient care?  The report provides few answers.

 

If meaningful change is to be made, clinical staff will be the ones to make it, and they can only do so with the right tools and information at their disposal.

 

Without appropriate tools, processes and culture in place, no amount of oversight will achieve the department’s lofty goal of zero preventable patient injury.  This is where ready-made systems like Osler plays a role by taking the high level principles identified in the Duckett review and applying them at individual patient, clinical manager and clinician levels.

How can Osler contribute to improved clinical governance?

Osler provides an opportunity for hospitals to be proactive in their patient safety efforts.  As Dr Duckett points out, hospitals should be operating within their defined scope of practice.  The problem is, few clinical managers have sufficient granular visibility of their activity to enable this to occur.  Using Osler to ensure all staff are adequately trained to perform invasive procedures, non-technical skills and basic equipment familiarity helps manage this clear and apparent risk.

 

By providing real time, meaningful and comparative data on clinical proficiency, complication rates and currency or practice, Osler enables hospitals to identify and respond to limitations in service levels and patient care.

 

And by creating a collaborative environment for clinicians, Osler can distribute these essential learnings across the healthcare system so that Victorians, indeed all Australians can be treated in a safer manner.

 

 

“You have to be willing to acknowledge your problems before you can remedy them. If I were to characterise the state of public and private hospital care in the state of Victoria, I’d have to say that this first step is lacking. Both the public and private hospital systems and the government regulators who oversee them are in a state of denial with regard to the level of harm being caused to the public by inadequate attention to quality and safety deficiencies.”

Paul Levy

former president and CEO of Beth Israel Deaconess Medical Centre in Boston, Massachusetts

Deakin University, Thinker in Residence, 2016

Osler Community Survey – Results

Thanks to all the respondents to our first Osler Community Survey!  The response rate we received was highly encouraging, and the feedback quite insightful in relation to professional development, clinical governance, credentialing, logbooks and desirable Osler product features.   We look forward to putting the input and feedback received to good use in the next versions of Osler and we will keep you apprised of the upcoming launch of Osler Community later this year via our newsletter and here on the blog.

 

Congratulations to N Kumta (Australia), M Hoops (Australia) and DP Bowles (UK), our three winners of the free 12 month subscription to Osler!

 

The infographic below provides a summary of your feedback and our findings.

Osler Clinical Performance

 

Or, you can download it from the link below:

Osler Survey (June 16) Results

Mobile Evaluations are Here

Mobile Evaluations – Osler Version 2

One of the features of Version 2 of Osler Clinical Performance that we are most excited about is mobile enabled assessments – an important component of a complete clinical governance system.

Evaluate your team and provide immediate feedback with evaluation for compliance and clinical areas such as:

  • Basic Life Support
  • Advanced Life Support (ALS)
  • Falls Prevention
  • Direct Observation of Procedural Skills (DOPS)

all from your handheld Android or iOS device!  Evaluate on the go so you can claim more of your precious time, and aren’t spending it filling out evaluations.

You can design Assessment Forms to support pass/fail, multiple choice and rating scales (level of mastery or competence) questions, and file uploads to incorporate evaluations into any Osler Learning training plans.

 

Combined with our mobile procedure supervision & evaluation,  Osler Clinical Performance can enable vastly improved clinical governance and provide a real time solution to your credentialing & compliance requirements.

Osler Clinical Performance Version 2 is available for providers and institutions now.  30 day trials can be accessed on the AppExchange.

 

Clinical governance assessment

Everyday heroes. Saving lives, one at a time…

I’m the COO here at Osler Technology.  I’ve had decades of experiences building businesses, developing software and helping clients achieve benefits through the use of that software.   But until I got involved at Osler, I was a complete novice in the inner workings of our health care system (still am!).  A recent event reminded me about why we are building Osler.

 

Earlier this week, one of our content editors (and a practicing nurse) witnessed a woman collapse on the steps to a supermarket across the road from our HQ in Noosa Heads, Queensland.  She immediately swung into action and commenced CPR and basic life support activities and called Todd, our founder (and a practicing intensivist), who was up the road having a coffee.   Between the two of them,  they kept this woman alive until transported to Noosa Hospital. 48 hours later, with a new stent in place, she was sitting up in bed, calling Jo & Todd her guardian angels.   Without the lucky coincidence of the timing and location, this woman probably would not have survived.

 

As our CEO remarked,  “Truly amazing to be involved in a software company where our team members actually go on to the street and resuscitate people who have had a heart attack.”

 

We’re building tools to help clinicians acquire new clinical skills and improve their clinical performance,   and to help providers be more efficient in developing and maintaining those skills among their workforce.  We know that these everyday heroes get it right 99% of the time.   But if Osler can help improve clinical governance, patient safety, and help those heroes get it right 99.1% of the time,  then it will be a huge win for public health,  patient safety,  and of course, our amazing team.

Osler Community Survey – Give us your views

We’re interested in your opinions about professional and clinical skills development, clinical governance and transparency in healthcare, and your feedback on our product ideas. Osler is developing a revolutionary new approach to professional development.

This survey shouldn’t take more than 8 minutes to complete & your feedback is incredibly valuable. We will distribute a summary of the aggregated results to all respondents at the conclusion of the research.

The best 3 answers to a question in the survey will also receive a free one-year subscription to Osler Community when it launches later this year.

LAUNCH SURVEY

 

Clinical Skills Development

Free Trial – Osler’s Clinical Governance application

Osler’s Clinical Performance Platform (CPP) is now available to trial on the AppExchange.

If you want to see how Osler CPP can:

 

  • improve your hospital’s approach to clinical governance
  • reduce costs of delivering mandatory training
  • help your staff improve their procedural skills by recording and measuring their procedural activity
  • provide immersive e-learning for a range of clinical procedures
  • give you at-a-glance views of your team’s clinical skills and procedural competence
  • improve patient safety

then go to the AppExchange Listing to sign up for a free 30 day trial with a fully configured application, including sample data.    Download the Osler TrialForce User Guide under the Details tab to help you get started,  and then click the [Get It Now] button.   You’ll be up and running in about 15 minutes!

 

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