It is in a sense unfair to focus on Djerriwarrah when we know that about 1 in 10 people entering our health services will suffer complications, about half of which are avoidable.
This figure is horribly high.
There was an audible gasp from the audience at a recent Minter Ellison seminar when the inaugural CEO of Safer Care Victoria, Professor Euan Wallace, noted that recently released sentinel event figures showed that the rates of retained pack (surgical instruments left in a patient during surgery – clearly an avoidable event) had remained stable for the last 6 years. That is, 8-10 people every year had had to return to surgery to remove surgical items. The same seminar looked at the safety lessons that can be translated from aviation to health care, drawing many parallels and some challenging comments from the audience. The level of avoidable harm tolerated in healthcare would simply be intolerable in aviation.
This heightened awareness of the very high levels of avoidable harm for patients, the terrible reality of that harm on the patients, their families, and the effect on healthcare professionals involved in these events has sharpened the focus on driving quality and safety culture.
There's no doubt this has to start from the top.
Healthcare leaders – boards, executives and clinicians - are certainly engaging with the content of the Duckett report. The report and its findings are a rich source of information and critical thinking about quality and safety in Victorian hospitals. While the focus is on the Victorian Department of Health's role in providing oversight of quality and safety, there's much valuable information for all health services, public and private. The language of the report is strong. Dr Duckett has said publicly that he doesn't want the report to be overlooked and the Department has rapidly embraced all of the panel's recommendations.
Healthcare leaders are interested in the new structures recommended by the report (Safer Care Victoria, Victorian Agency for Health Information and the Victorian Clinical Council.) There is also the prospect of new legislation dealing with quality and safety later this year.
In the meantime, many of our healthcare clients are taking the opportunity to think deeply about how they can drive safety and quality from the top. How do you move towards zero patient avoidable harm? How do you move your organisation from a reactive safety culture to a pro-active one? Do we focus too much on compliance rather than ways to foster continuous improvement? How do you manage clinical governance risk?
Here's 5 questions to do your own health check on clinical governance:
1. Do we really understand the components of our current clinical governance framework?
Have we looked critically at our current framework? There are many tools available to create or review your framework – how do you shape up against them?
2. Are we monitoring the right aspects of quality and safety at the right levels?
Who should be monitoring what? It's vital that the right things are monitored at the right level so that the whole system can be integrated. For example, clinicians must know what clinical practice will minimise risk and how to implement those treatments properly. Clinical leaders must know what good systems of practice look like and whether clinicians are providing appropriate care. . The CEO must know whether clinical leaders know what good systems of practice look like and whether clinical leaders are responding appropriately. The Board must know whether systems are in place so all other accountabilities are working. All of this requires good comparative and trend data, especially at board level. There's much work to be done here identifying the lead and lag indicators that really matter for the core operations of your organisation.
3. Is the flow of quality and safety information in our organisation effective?
Is each level of the organisation receiving the right information to fulfil its role? At Board level what information should you be seeing? We know from the Centro case that Boards can't be passive about the information they need. If you're a director and you think you need certain information in a certain format, ask for it!
4. Is there a sufficient skill set at Board level to deal with quality and safety?
Do we have enough clinical governance expertise at Board level? The Duckett report contains a very helpful skills rubric which you can use to assess your Board's clinical governance expertise.
5. How do we train and care for our workers?
Staff safety and wellbeing are integral to driving a culture of safety and quality. Adverse events can seriously affect staff wellbeing, motivation and morale. What are our support mechanisms for staff who are exposed to adverse events? How do we support whistle blowers?
How good is our training? To what extent do we focus on working in teams? To what extent does our training develop a "just" culture which supports a high reporting, 'no blame' atmosphere?
Critically engaging with your organisation's clinical governance framework is a valuable step in the marathon work of driving a dynamic safety and quality culture. The sustainability of our healthcare services will increasingly depend on safety and quality performance, particularly as data reporting becomes more publicly available. But most importantly, the imperative for healthcare leaders in grasping the challenge of quality and safety improvement is emphatically stated in the Duckett report: "Lives are precious".