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

“How many of these have you done?”

A recent opinion piece in the Journal of the American Medical Association drew attention to the issue of procedural experience in healthcare.

 

Titled “How many have you done?”, the piece described the experience of a doctor who required a procedure herself, in this case, an amniocentesis.

 

Of course, what the patient was really asking is, “How can I be reassured you know what you are doing?”

 

The thrust of the piece was that the training doctor who performed the procedure had felt compelled to misrepresent their experience with the technique, deftly deflecting questions by the patient and her partner that explored his competence.  The author calls for a more honest response to these types of questions, while acknowledging that this is often difficult to do.

 

But is it any wonder a young doctor has trouble answering this question?

 

Healthcare continues to battle with the issue of competency.  It is still rare for doctors to be formally certified to perform specific procedures.  In fact, the industry still does not have a shared understanding of what competency actually is!

 

Furthermore, because it is uncommon for doctors to assiduously record their activity and outcome data, and even more rare for them to benchmark against their peers, most clinicians are simply oblivious to performance level.

 

So when patients are searching for reassurance that they will be cared for as best they can be, most of us struggle to be clear and meaningful in our response.  Because most of the time, we just don’t know.

 

Wouldn’t it be much better for the junior doctor to answer with authority?

 

“Well, I’ve completed a recognized pathway and been certified to practice after a period of supervision by experts.  Furthermore, I continuously review my performance results and feel comfortable that I’m doing well.”

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Clinical Skills Development

The 3rd leading cause of patient death might well be the hospital system itself

Another week, another report illustrating the harm that the healthcare industry inadvertently causes to its patients.

 

This week the British Medical Journal published a report by renowned patient safety champion Marty Makary which examines the role of healthcare error on mortality.

 

Healthcare error take many forms, including :

  • Unintended acts (either commission or omission)
  • Execution errors
  • Interpretation and synthesis errors
  • Planning errors, and
  • Deviations from processes of care

 

The report highlights the lack of visibility surrounding healthcare error. Annual causation mortality data is often compiled from death certificates and coding, based on classifications such as the International Classification of Diseases (ICD) code.   Such systems do not routinely account for healthcare error, and so do not feature on such annual lists.

 

The fact that healthcare error results in patient deaths comes as no surprise to most practicing clinicians, many of whom have either witnessed patient deaths related to management errors, or even been a part of the process themselves. And it’s not a pleasant experience.

 

What should be startling is that the issue has been recognized for so long, yet little progress seems to have been made. It’s now over 15 years since the seminal work of Lucian Leape and colleagues (1) highlighted as many as 98 000 American lives are lost each year related to iatrogenic factors in hospitals, with countless more injured. Many of these deaths are thought to be potentially preventable.

 

Despite the furore that Leape’s To Err is Human report generated, little seems to have changed. Subsequent reviews (2-6) have since estimated that between 200 000 and 400 000 US deaths can be connected to patient error annually.

 

Extrapolating the published literature, Makary and colleagues suggest that, if true, iatrogenic causes of death would rank third on the all-cause mortality table in the US (behind heart disease and cancer).

 

It’s hard to imagine that if healthcare error was viewed as a disease, widespread public awareness campaigns, fundraisers and dedicated research would be inevitable.

 

No one who works in healthcare could possibly suggest that a zero patient death rate due to iatrogenesis is possible. The healthcare system is almost as complex as the humans it cares for. It’s clear that the vast majority of patients who traverse the system are well cared for by highly motivated and caring individuals, and the results are usually positive.

 

That notwithstanding, healthcare needs to re-evaluate its approach to safety. The external perception of the acute care industry is that of a High-Reliability Organization, where safety is prioritised against all other factors. Industries such as oil and gas exploration, aviation, and nuclear power have demonstrated that this approach can reduce injury to almost zero.

 

The serial failure of our industry to embrace standard, risk averse behaviours contributes greatly to the harm it generates :

 

  • Failure of orientation
  • Failure to validate procedural competence
  • Failure to ensure equipment familiarization
  • Failure to embed policy and procedural change
  • Failure to embrace literature and national standards
  • Failure to embrace technology that can improve and enhance safety standards
  • Safe working hours
  • Failure of process documentation and audit
  • Communication failure
  • Failure to measure and report outcomes transparently
  • Failure to ensure critical incident learnings are widely distributed
  • Failure to report and investigate “near miss events”
  • Failure to create a no-blame culture

 

Applying these principles to the healthcare sector will inevitably create tensions and encounter barriers to implementation, but the first step is an acceptance that we can do better.

 

“I think doctors and nurses and other medical professionals are the heroes of the patient safety movement and come up with creative innovations to fix the problems,” he said. “But they need the support from the system to solve these problems and to help us help improve the quality of care.” Marty Makary (source CNN)

 

 

References

  1. Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system.National Academies Press, 1999.
  2. Leape LL, Lawthers AG, Brennan TA, Johnson WG. Preventing medical injury. Qual Rev Bull1993;19:144-9.pmid:8332330.
  3. HealthGrades quality study: patient safety in American hospitals. 2004. http://www.providersedge.com/ehdocs/ehr_articles/Patient_Safety_in_American_Hospitals-2004.pdf.
  4. Department of Health and Human Services. Adverse events in hospitals: national incidence among Medicare beneficiaries. 2010. http://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf.
  5. Classen D, Resar R, Griffin F, et al. Global “trigger tool” shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff2011;30:581-9doi:10.1377/hlthaff.2011.0190.

American Hospital Association. Fast facts on US hospitals. 2015.http://www.aha.org/research/rc/stat-studies/fast-facts.shtml

 

About the author

Dr Todd Fraser is a passionate campaigner for patient safety through better process.  He is an Intensivist and Retrieval Physician, and co-founder of Osler Technology.

Free Trial – Osler’s Clinical Governance application

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

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  • 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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