In my travels around the world, I've come to realize that the normal state of hospital quality and safety is pretty consistent. As Captain Sullenberger put it: "Islands of excellence in a sea of systemic failures." That's no reason to give up hope that things will improve, but this description does offer a metric of sorts and acts to prompt a number of us in the field to continue to push for better care and offer training and assistance to health care professionals.
But Sully's summary is inadequate in one respect in that it doesn't reflect those institutions that are remarkably worse than even the substandard norm. There are examples everywhere. In the US, it was exemplified by Parkland Memorial Hospital in Texas. In the UK, it was Mid Staffordshire. Here in the state of Victoria, it is Djerriwarrh.
I'd heard about this story of the Bacchus Marsh hospital unit of Djerriwarrh Health Services well before arriving in Australia. Preventable deaths of babies is news that spreads worldwide, and this cluster from 2013-2015 at this low-risk maternity center was no exception.
There is a lot of blame going around still, months later. There is also thoughtful analysis.
[A] review led by Professor Euan Wallace found the perinatal mortality rate at the hospital was significantly higher than the state average and much higher than expected for a "low risk" unit.
He also identified misuse or misinterpretation of foetal heart rate monitors by "inadequately skilled" staff and a lack of "high quality staff education" as key problems.
But that's only part of the problem. It is evident that this hospital suffered from a serious failure of governance. Indeed, the community board has since been sacked by the state government. Beyond their own lack of expertise, the board countenanced a committee structure that reported only to the CEO and not to the board. There was essentially no quality and safety committee, and adverse events that occurred were improperly categorized as of lower acuity, so that root cause analyses were not undertaken. Doctors also were practicing outside of their scope of authority, delivering babies in higher risk situations than their hospital was authorized to perform.
But the place also suffered from a "compliance" mindset on the part of the hospital's leadership: As long as forms were on file and reports filed in timely fashion, the job was being done well. This attitude may have been reinforced by the ACHS, the Australia equivalent of the Joint Commission, which had graded the hospital highly in the survey before these disclosures.
(In a wonderful bit of irony, the Health Services still posts this message on its website, even though its most recent, post-disclosure ACHS review was less than stellar:
The Health service is an industry leader in a number of quality standards that cover a wide variety of issues including actual clinical care, how the organisation is managed, infection control, risk management and emergency procedure planning. Djerriwarrh Health Services is currently accredited through the Australian Council of Healthcare Standards (ACHS) as well as the Aged Care Standards Agency.)
Things were compounded by a failure of the AHPRA, the national board of physician registration, to conduct timely and accurate reviews of complaints about physicians, and their failure to inform hospital officials that such reviews were even in progress. Meanwhile, Professor Wallace also found that the state Department of Health, itself, had failed to use the data at its disposal to notice adverse trends in clinical outcomes. It was not until March 2015 that the Department noted the hospital's problems in the maternity arena.
Sorry to say, but none of this is a surprise. And I wouldn't be surprised if future investigations turned up more typical aspects of such cases. I'd bet that there was a culture of bullying and intimidation. I'd bet that there was poor communication among the elements of the medical staff who were involved in obstetrical care. I'd bet that there was poor team dynamics. I'd bet, too, that once people look back further in history, they will find still more cases of preventable harm. And I'd bet that they will find it in other clinical areas delivered by Djerriwarrh Health Services.
So, where does this lead, for Djerriwarrh Health Services and for the state? Victoria is characterized by a very high number of very small health services. Here's a map of the state showing the distribution of public hospitals.
This large number of very small rural hospitals is the result of political forces, not a rationalized plan based on geography, demographics, health needs, or critical masses. It means that several dozen small hospitals function essentially in the same manner as Djerriwarrh, with isolated medical staff and well meaning, but medically inexperienced boards.
Does the Djerriwarrh story suggest that the state should move to a more hub-and-spoke system of hospital organization, with greater reliance on regional higher acuity centers? That's for the body politic to consider. (It is not for a visitor to offer opinions on that kind of issue!)
Regardless of whether the state moves in that direction, though, there's a clear need to raise the level of the lay governing boards--to train them how to govern quality and safety--and to institute more rigorous clinical governance systems among the medical staff themselves. The case also suggests that some review of the regulatory and accreditation bodies is in order. Among other things, shouldn't the ACHS survey findings be made public as a matter of course? Quis custodiet ipsos custodes?
And finally, transparency. The sunshine that comes from public display of real time (not historical) clinical outcome trends is the most certain way achieve the standard of care that clinicians desire for their communities. As I noted years ago:
Transparency's major societal and strategic imperative is to provide creative tension within hospitals so that they hold themselves accountable. This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care.
Djerriwarrh stands in the middle of one of the fastest growing regions in Victoria. The current and future residents of that area deserve the best in clinical services. There is nothing standing in the way of the well meaning people at Djerriwarrh Health Services from committing themselves to deliver the best.
But Sully's summary is inadequate in one respect in that it doesn't reflect those institutions that are remarkably worse than even the substandard norm. There are examples everywhere. In the US, it was exemplified by Parkland Memorial Hospital in Texas. In the UK, it was Mid Staffordshire. Here in the state of Victoria, it is Djerriwarrh.
There is a lot of blame going around still, months later. There is also thoughtful analysis.
[A] review led by Professor Euan Wallace found the perinatal mortality rate at the hospital was significantly higher than the state average and much higher than expected for a "low risk" unit.
He also identified misuse or misinterpretation of foetal heart rate monitors by "inadequately skilled" staff and a lack of "high quality staff education" as key problems.
But that's only part of the problem. It is evident that this hospital suffered from a serious failure of governance. Indeed, the community board has since been sacked by the state government. Beyond their own lack of expertise, the board countenanced a committee structure that reported only to the CEO and not to the board. There was essentially no quality and safety committee, and adverse events that occurred were improperly categorized as of lower acuity, so that root cause analyses were not undertaken. Doctors also were practicing outside of their scope of authority, delivering babies in higher risk situations than their hospital was authorized to perform.
But the place also suffered from a "compliance" mindset on the part of the hospital's leadership: As long as forms were on file and reports filed in timely fashion, the job was being done well. This attitude may have been reinforced by the ACHS, the Australia equivalent of the Joint Commission, which had graded the hospital highly in the survey before these disclosures.
(In a wonderful bit of irony, the Health Services still posts this message on its website, even though its most recent, post-disclosure ACHS review was less than stellar:
The Health service is an industry leader in a number of quality standards that cover a wide variety of issues including actual clinical care, how the organisation is managed, infection control, risk management and emergency procedure planning. Djerriwarrh Health Services is currently accredited through the Australian Council of Healthcare Standards (ACHS) as well as the Aged Care Standards Agency.)
Things were compounded by a failure of the AHPRA, the national board of physician registration, to conduct timely and accurate reviews of complaints about physicians, and their failure to inform hospital officials that such reviews were even in progress. Meanwhile, Professor Wallace also found that the state Department of Health, itself, had failed to use the data at its disposal to notice adverse trends in clinical outcomes. It was not until March 2015 that the Department noted the hospital's problems in the maternity arena.
Sorry to say, but none of this is a surprise. And I wouldn't be surprised if future investigations turned up more typical aspects of such cases. I'd bet that there was a culture of bullying and intimidation. I'd bet that there was poor communication among the elements of the medical staff who were involved in obstetrical care. I'd bet that there was poor team dynamics. I'd bet, too, that once people look back further in history, they will find still more cases of preventable harm. And I'd bet that they will find it in other clinical areas delivered by Djerriwarrh Health Services.
So, where does this lead, for Djerriwarrh Health Services and for the state? Victoria is characterized by a very high number of very small health services. Here's a map of the state showing the distribution of public hospitals.
This large number of very small rural hospitals is the result of political forces, not a rationalized plan based on geography, demographics, health needs, or critical masses. It means that several dozen small hospitals function essentially in the same manner as Djerriwarrh, with isolated medical staff and well meaning, but medically inexperienced boards.
Does the Djerriwarrh story suggest that the state should move to a more hub-and-spoke system of hospital organization, with greater reliance on regional higher acuity centers? That's for the body politic to consider. (It is not for a visitor to offer opinions on that kind of issue!)
Regardless of whether the state moves in that direction, though, there's a clear need to raise the level of the lay governing boards--to train them how to govern quality and safety--and to institute more rigorous clinical governance systems among the medical staff themselves. The case also suggests that some review of the regulatory and accreditation bodies is in order. Among other things, shouldn't the ACHS survey findings be made public as a matter of course? Quis custodiet ipsos custodes?
And finally, transparency. The sunshine that comes from public display of real time (not historical) clinical outcome trends is the most certain way achieve the standard of care that clinicians desire for their communities. As I noted years ago:
Transparency's major societal and strategic imperative is to provide creative tension within hospitals so that they hold themselves accountable. This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care.
Djerriwarrh stands in the middle of one of the fastest growing regions in Victoria. The current and future residents of that area deserve the best in clinical services. There is nothing standing in the way of the well meaning people at Djerriwarrh Health Services from committing themselves to deliver the best.
2 comments:
Very true. Its the same way here: politics/drama in the administration and complicity with doctors leads to disaster for people. The only way to stop it is by more transparency and harsher laws & reprecussions for administration and doctors.
I'm disgusted enough to make noise because good doctors, good admin do not deserve to have their hard work/ethics tarred and feathered by people who do these things. Stand up for what is right.
AMEN ANONYMOUS !!!!!!!! Couldn't of said it better myself....
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