Quality Improvement Committee He iti rā, he iti māpihi pounamu - A small contribution can be as valuable as a precious stone 1. Introduction The Quality Improvement Committee (formerly EpiQual) is a statutory committee established under the New Zealand Public Health and Disability Act 2000. It is appointed by, and accountable to, the Minister of Health. The members of the Quality Improvement Committee are appointed by the Minister of Health. The current chairperson for the Committee is Patrick Snedden. 2. Purpose of the Committee The role of the Quality Improvement Committee is to provide advice to the Minister on any health epidemiology and quality assurance matters, including sponsoring, monitoring and evaluating programmes within the Improving Quality (IQ) Action Plan. It must specifically deal with perinatal, maternal, infant, child and adolescent morbidity and mortality issues. The Quality Improvement Committee will work across the health and disability sector (with a particular focus on hospital care) as both an advisor and a facilitator. In providing its advice it must: a. ensure that there is a capacity to improve health outcomes through quality improvement programmes including those directed to clinical providers b. seek to develop a shared learning environment in the health sector, thereby quickening the implementation of innovation and the continual achievement of best practice c. provide a national perspective of the variety of accountability mechanisms in the health and disability sector including, ethics, negotiated targets, societal demands, investigative and disciplinary systems and other formal accountability mechanisms d. ensure, to the maximum extent practicable, that there is national co-ordination in the reporting of relevant health epidemiology and quality assurance matters e. identify that quality in healthcare and disability support is always everyone s business, and that improving quality is continuous and is supported by professionalism, technology, experience, a pervasive ethos of care and by the quest for better value for money f. apply a broad definition of quality that is strongly associated with safety, value for money, people-centred care, high performance and best practice.
The advice given to the Minister is to be formulated after consultation by the Committee with District Health Boards and other persons involved in the provision of services, and any other persons that the Committee considers appropriate. 3. Principles of the Committee Transparency The Committee will demonstrate transparent decision-making processes by ensuring information is available to the public when and wherever possible. Leadership The Committee will provide leadership within the New Zealand health sector on all matters related to quality. Quality Improvement The Committee will focus on improving quality within the New Zealand health sector. Evidence-based The Committee will make decisions based on evidence whenever possible. Outcome focused The Committee will focus on improving health outcomes from an individual and population perspective, considering the broader determinants of healthcare. Advisory The Committee will provide advice to the Minister that encompasses the above principles. 4. Work Programme The Quality Improvement Committee will perform the following key tasks. - To provide independent advice to the Minister on quality improvement in the health sector through monitoring of national quality initiatives and to advise the Minister on how clinical outcomes may be improved through such initiatives. - To advise on data which needs to be collected, using and streamlining existing data collection systems where possible, to enable national conclusions to be drawn. - Give advice on priorities for epidemiological studies that will assist in improving clinical outcomes. In developing its advice, the Committee will consider reports referred to it, including the following: - Child and Youth Mortality Review Committee, and any other mortality review committee set up under Section 18 of the Act - New Zealand Health Sector Quality Improvement Strategy - Reportable Events Monitoring System - Competency reviews under the proposed Health Professionals Competency Assurance legislation - Compliance with the Health and Disability Services (Safety) Act 2001 - Opinions of the Health and Disability Commissioner, under Section 45 of the Health and Disability Commissioner Act 1994. It will also:
- Identify data quality and analysis issues, identify information gaps and make recommendations on how to learn from, and prevent, system failures. - Consider such matters as the Minister specifies by notice to the Committee, such as reporting on perinatal mortality review. - Advise the Minister on clinical epidemiological matters that will improve clinical practice quality and support other quality assurance initiatives. - The Committee may also commission, co-ordinate or undertake research projects for the development of advice but, where possible, build on existing and previous reports and policy work 5. National Quality Improvement Programmes The most important quality improvement activities are frequently those activities that are planned and undertaken by the staff who deliver services directly to consumers. However, health care has become increasingly complex and a strategic, consumer-focused, approach to quality improvement at all levels within the system is vital. The Quality Improvement Committee (QIC) has initiated a coordinated national approach to quality improvement to address quality and safety problems within public hospitals because the greatest risks are in this part of the health care system. However, there are more quality improvement opportunities than there are resources to address them, so the following programmes have been prioritised to achieve value for money and higher quality services. Each of the National Quality Improvement Programmes has been given to a lead DHB for implementation. The programme details and contact information are included in the links below. Optimising the Patient s Journey Management of Healthcare Incidents Infection Prevention and Control Safe Medication Management National Mortality Review Systems 6. THE FIVE PROGRAMMES a. Optimising the Patient s Journey This programme is based on a national collaborative approach to implementing effective processes in all DHBs for optimising the flow of patients and improving their journey through the health system. A key mechanism for improving the quality of patient care, particularly in hospitals, is to look at the patient s journey through the system as a whole. This analysis is taken from both the patient s perspective and from a whole system perspective, in order to optimise the flow of patients and allocation of resources at every step of the journey. The programme will focus on improving the patient s journey within the inpatient setting, from before the patient s entry (i.e., attendance at the Emergency Department or at outpatient medical and surgical services) until the patient is discharged from that episode of care. The programme will also focus on the management of patients with chronic diseases who present at the hospital for
treatment, and on the flow of patients from the community/primary care setting through to the hospital setting. Lead DHB: Counties Manukau District Health Board Programme Contact: Allan Cumming b. Management of Healthcare Incidents The complexity of healthcare means that accumulated simple errors can lead to major system failures and harm to patients. All human operators can make errors at times, but the system of care is not always designed to identify errors and prevent consequent patient harm. A systematic approach to identifying and analysing common causes of system failure allows the redesign of patient care processes to eliminate repeated harm. Furthermore, a standardised approach to the management of major incidents can ameliorate patient risk and harm by swiftly mounting the most effective response. It is essential to develop the right culture and environment within which all components of incident management can occur. A fundamental component of the culture that is to be achieved is one that is caring and compassionate and one in which the disclosure of adverse events is open and truthful. About 10-15 percent of hospital admissions are associated with an adverse event. While all DHBs have systems for identifying and responding to such event, their approaches are inconsistent and the national guidelines on managing reportable events has been implemented in various ways. Some DHBs are developing their own information systems for managing incidents, whereas others have identified off the shelf systems for this purpose. Some DHBs train staff in incident management, including open disclosure and the process of root cause analysis, whereas others provide no training. Incidents vary from simple errors, without patient harm, up to major reportable events associated with permanent harm or death of a patient. A uniform incident management system needs to classify the magnitude or severity of incidents and define a hierarchy of responses. System learning comes from aggregated data from large numbers of low-level events and the in-depth investigation (including root cause analysis) of cases or serious patient harm. Incident management is a key strategy being used by health services for managing the risks of clinical care as well as for managing corporate risks. When implemented correctly, incident management is an effective mechanism for systematically identifying and managing problems and failures in the system and for informing the development of preventive strategies. It also guides the immediate response to incidents, with the purpose of minimising risk and further harm. Lead DHB: Waikato District Health Board Programme Contact: Maureen Robinson c. Infection prevention and control Infections that have been contracted in the health care system are a significant problem worldwide. Reducing these infections has been identified as a priority because of the disease burden and the economic burden that these infections create. At any one time, over 1.4 million people worldwide are suffering from
infections acquired in hospital and up to 10% of patients admitted to modern hospitals in the developed world acquire one or more infections. Healthcare associated infections in England are estimated to cost 1 billion a year. In the United States, the estimate is between US$ 4.5-5.7 billion per year. Surgical site infections: - account for about 14% of possible adverse events threatening patient safety in hospitals in developed countries - occur in at least 5% of the patients undergoing surgical procedures every year - prolong hospital stay on average by 7.4 days, at an average cost of $1000 per day. The importance of this issue in New Zealand has been highlighted in the Controller and Auditor-General s Report in 2003. The Controller and Auditor- General reported on the management of hospital-acquired infections in public hospitals in New Zealand and described and assessed systems for managing these infections in public hospitals. One of the leading causes of healthcare-associated infections is the failure to comply with hand hygiene because the lack of hand hygiene contributes to the spread of multi-resistant organisms and is recognised as a significant contributor to outbreaks of infection. The potential benefit of successful hand hygiene promotion outweighs its costs, and widespread promotion should be supported. The excess use of hospital resources associated with only four or five serious healthcare-associated infections may equal the entire annual budget for hand hygiene products used in patient care areas. The cost to patients is also significant in terms of prolonged recovery, delays in returning to employed work and/or usual activities as well as costs related to assistance and extra appointments and follow-up needed during this time that is not covered by health or support services. These costs are often invisible costs that are not included in economic calculations. Lead DHB: Auckland District Health Board Contact: Greg Balla d. Safe Medication Management Medication is one of the most common therapeutic interventions used in the health care system, and medication errors in hospitals or the community are common. Approximately 1.6 percent of people admitted to hospital may experience an adverse medication event. Of these events, the majority are preventable and occur inside hospitals. Preventable adverse events have a significant impact on consumers. About 3.1 percent result in death and 8.3 percent in permanent disability. Several strategies have been proven to be effective for reducing the rate of errors in medication management. They include: the use of a standardised medication chart across a whole organisation or sector reconciling, effectively and continually, a patient s medication list, particularly when the
patient is transferring from one part of the health system to another the introduction of some safety mechanisms around the use of high risk drugs verifying medications at the bedside, using barcoded point-of-care systems using an electronic prescribing system The Government announced in Budget 2007 that $10.2 million has been made available to improve patient safety using bedside verification of drugs. This project is often incorrectly referred to as the barcode project. Rather than just involving barcoding of patients and medication, it involves a co-ordinated range of components aimed to address parts of the medication administration sequence because many of these components need to be improved. In addition, the new systems and processes will need to be introduced and linked to each other. Lead DHB: Hutt Valley District Health Board Contact: Clare Kirk Clare.kirk@huttvalleydhb.org.nz Website: www.safemedication.org.nz e. National Mortality Review systems (NOT YET STARTED)