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.
To this end, the report makes several important recommendations, among them :
- The department must set a clear example to the wider health service that this issue is its number one priority
- The system should focus less on “meeting accreditation standards”, and instead greater emphasis placed on outcome monitoring
- 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
- Performance of the health service is more effectively monitored, by making better use of available data and filling in gaps as they exist
- Improvements are made in the utilization of data, so that the entire system can benefit, and learnings are better shared
- All hospitals should be open to periodic external review
- That hospitals are held to account in only providing care that falls within its scope of capability
- 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.”
former president and CEO of Beth Israel Deaconess Medical Centre in Boston, Massachusetts
Deakin University, Thinker in Residence, 2016