Saturday, March 12, 2016

Getting past denial in Victoria

You have to be willing to acknowlege your problems before you can remedy them.  If I were to characterize the state of public and private hospital care in the state of Victoria, Australia, I'd have to say that this first step is lacking.  Both the public and private hospital systems and the goverment 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. The health system as a whole, also, is characterized by an uwillingness to engage patients and families in the appraisal and improvement of care.

The question is when and if the body politic and hospital governing bodies and clinical and administrative leaders will overcome their denial of the extent of the problem.

On the public side of the hospital system, the Victoria Auditor-General is about to issue an important report on patient safety in Victoria hospitals, described as follows:

Clinical incidents in healthcare settings cause, or have the potential to cause, unexpected harm to patients. They include falls, pressure sores and medication errors and may result in near misses, adverse events where harm has occurred or sentinel events resulting in serious harm or death. It has been estimated that around one in 10 hospitalised patients suffers preventable harm and an adverse event related to care. The number of near misses, the accuracy of reporting of patient safety incidents, and the effectiveness of subsequent investigation are not known. The audit will determine whether public hospitals are managing risks to patient safety.

If this study is rigorous and accurate, as I have reason to believe it will be, it will confirm a previous analysis about the public hospitals:

A study published in the journal Health Policy showed there were almost 20,000 adverse events - or incidents that cause harm to patients - in Victoria in 2005-06.

The data showed for the first time the extent of errors and complications in Victoria's hospitals and highlighted how little the state government reports such problems. It discloses only the most serious problems, or ''sentinel events'', each year.

In 2005-06, the same year as the study, it disclosed only 91 serious adverse events, including 29 deaths.

The study, led by Katharina Hauck of the Imperial College London's centre for health policy, found that adverse-event rates varied greatly between hospitals - from 6.8 per cent to 30.1 per cent for elective and from 3.6 per cent to 25.7 per cent for emergency patients.

Many believe that quality and safety problems occur mainly in the rural hospitals, but it is clear that they exist even in the most reknowned academic tertiary care institutions.

From all I can see, this study has been ignored by the body politic.  After a brief flurry of interest by media, attention to the issue evaporated.  Will the same happen to the Auditor-General's report?  Concerns about the public health system tend to focus on budgetary matters, sometimes with sniping between federal and state officials that distracts from the level of harm being caused to patients.

There is a tendency among Victorians to extol the virtues of the devolved model of health care organization that exists in the state--as distinct, say, from the more centralized approach employed in New Soulth Wales.  In that state, a Clinical Excellence Commission is directly charged with designing and disseminating improvements in patient care into the state's hospitals.

There is no inherent advantage in one system versus another.  After all, a devolved system can be a fecund environment for innnovation and creativity.  But when it comes to the saftey and quality of care, there is scant evidence that such is the case in Victoria.  An October 2015 study by the King's Fund is notably silent about any such advances.  Apparently looking for positive remarks, the best the authors could say was the following:

The picture that emerges is of a health system performing well. Available data shows that Victoria delivers good results in comparison with other parts of Australia, being at, close to and sometimes above the average on many indicators. Underpinning Victoria’s performance is a well-understood governance model that gives the boards running health services at a local level considerable autonomy within a state-wideframework of priorities.

Putting aside the fact that benchmarking a system to "the average" is meaningless,  the following remarks undercut the validity of even this conclusion:

The transparent reporting of data on performance is another area for improvement. Not only would this strengthen accountability to the public, but also it would support health care providers to compare their performance with others and identify areas in which they can improve. The ‘disinfectant of sunlight’, as it has been dubbed, is being used increasingly in other health care systems, including within Australia, and it could be a powerful means of providing an early warning of performance problems. Increased transparency on safety and quality would also provide boards with the information they need to discharge their responsibilities.

In short, the basic information that devolved boards need to carry out their responsibilities is simply not available.

All of the above is about the public hospitals, but I have now heard and seen enough to believe that similar patterns exist in even some of the most highly regarded private hospitals.  During the last three months, I did not seek stories of safety and quality lapses in the private system, but I've had many reported to me.  One hospital system, for example, has a clear and persistent pattern of mis-identifying patients under their care--sometimes from failing to attach identifying name bands to patients admitted through their emergency room--resulting in near misses as patients were sent to the wrong procedure rooms or were about to be administered the wrong medications.

As in the case of the public hospitals, as dearth of reporting about hospital acquired infections and other sources of harm impedes public debate about this important adjunct to the state's health system. A lack of transparency allows reputation and market power--rather than quality--to form the basis for the relative rates charged to private medical insurers.

I have discussed before the high level of communitarian behavior in much of Australia society, and this is a marvelous thing.  I have also pointed out the notable personal commitment of many clinicians to providing patient- and family-centered area.  This too is admirable.  But general evidence of communitarianism and caring do not make a safe and high quality health care system.  Unless there is a high-level and sustained commitment to reducing harm by Government, by boards, and by clinical leaders; unless all parties embrace transparency of clinical outcomes; and unless patients and family engagement is made an institutional requirement of care design and delivery, Victorians will be put at unnecessary risk during their visits to public and private hospitals in the state.


Victoria Nahum said...

From Facebook:

When our son died of medical harm a nurse told me that their hospital was within the normal metrix for harm. I say, "There IS no acceptable metrix for any sort of harm because preventable harm of any kind at any time should never be considered the norm."

Unknown said...

It is really disappointing to see the 'same old, same old' rearing its hideous head again. It sounds like there is a 'sounds good' mentality of wanting to change things, but, when it comes down to it, not a will to do what it will take to make everyone safer. This is tragic as lives are being lost or damaged through inaction and denial.

Anonymous said...

Your blog is insightful and sadly an accurate account of the state of affairs in Victoria. Whilst by most standards Victoria’s healthcare system is ‘good’ (or as you point out above the substandard norm!) …significant changes are required to consistently deliver truly ‘great’ care. We’re unfortunately another poignant example highlighting that ‘good is the enemy of great’. Our lack of data transparency lulls us into a false sense of confidence and results in the absence of a burning platform to drive much needed improvements. Despite evidence of serious failures and deficiencies in our healthcare system (such as the recent case of Djerriwarrh), it's disappointing we still can’t ‘get past denial’ and continue to have incidents resulting in avoidable patient harm.

I’m encouraged on a daily basis by many like-minded people who share a focus on pursuing initiatives that create safer and more positive experiences for our patients. Whilst there is clearly a long road ahead… I’m hopeful that collectively we can create greater patient engagement, improve the quality of care, build more effective governance systems and make a difference that will benefit patients. The question is how many patients will be adversely affected in the time it takes to ‘get past denial’ and build enough momentum for change across the entire Victorian healthcare system?