WHO Patient Safety Alliance Workshop Amsterdam October 19 2004 Why measure? Overview of previous research experience Dr Ross McL Australian Council for Safety and Quality in Health Care Director, Northern Centre for Healthcare Improvement, Sydney
Six Domains of Quality Safe Appropriate Efficient Patient s s view Acceptable Effective Accessible
Model for Improvement 1. What are we trying to accomplish? 2. What changes can we make to improve? 3. How will we know that a change is an improvement? Act Plan a change Study its effects Do it in a small test
History Not a new problem Not seen as anything more than a natural consequence of doing the best we can we limited knowledge, skill or resources came to attention of patients and politicians through the media, reframed as health care causing preventable harm or death
Medication Errors In the past two years: AUS CAN NZ UK US Given the wrong medication or wrong dose by a doctor, hospital or pharmacist 11 11 13 10 12 Believed a medical mistake was made in your treatment or care 19 20 18 13 23 Medication error or believed an error was made 23 25 23 18 28 2002 Commonwealth Fund International Health Policy Survey Adults with health problems.
Broad based published studies Strong (larger) hospital focus Obstetric and mental health care often excluded necessarily under-estimate estimate the size of the problem divide into negligence studies with AE rates ~ 3-4%; 3 and improvement studies with AE rates around ~10% + have reasonable reliability on AE causation, but less on preventability The harder you look the more you find
Studies Harvard Medical Practice Study Utah Colorado Study Australia New Zealand UK Denmark Canada Japan Singapore Preventability ~ 50% Negligence AE 2.9-3.7% AE Rate ~ 10% (7.5-16.6)
QUALITY IN AUSTRALIAN HEALTH CARE STUDY to estimate the prevalence of INJURY to patients caused by their HEALTH CARE by measuring ADVERSE EVENTS judging PREVENTABILITY of these events assessing DISABILITY from these events RM, Runciman WB, Gibberd RW et al., The Quality in Australian Health Care Study. Med J Aust 1995
QAHCS Summary of Results 16.6 % of hospital admissions were associated with an adverse event ~400,000 /year 51 % of AEs were judged to be preventable 240,000 admissions/year ~ 1,700,000 bed days 46.6 % of AEs resulted in minimal disability 13.7 % of AEs resulted in permanent disability 50,000 cases/year 4.9% of AEs resulted in death 18,000/year ~ 50% preventable
QAHCS Elective Surgical Procedures Procedure AEs % Major joint replacement 33.3 Coronary artery bypass grafting 29.2 Hysterectomy 20.8 Transurethral resection prostate 17.2 Knee arthroscopy 16.0 Herniorrhaphy 15.9 Cholecystectomy 13.9 Cataract extraction 6.5 Tonsillectomy 5.4
Patient Safety In clinical context
Clinical Consequences of Surgical AEs 30% 25% 20% 15% 10% 5% 0% Infection Unrelieved PO Blee d Pain Cardiac Resp DV T/PE
Patient Safety In resource usage context
Resource Consequences of Surgical AEs 40% 35% 30% 25% 20% 15% 10% 5% 0% Readm it Ret OR SS Addit M eds Ext LOS Drain/IDC Unpl s urg/tract
Patient Safety as a Public Health Risk Peter Davis CMAJ May 25, 2004;170(11) Of the top 20 risk factors that account for 75% of all deaths annually, adverse in-hospital health care is number 11 ahead of air pollution, alcohol and drugs, violence and road traffic injury, etc one third the size of tobacco related death
Patient Safety as a human right Peter Davis CMAJ May 25, 2004;170(11) Informed consent about risk open disclosure when things go wrong Organisational Learning from adverse events compensation, timely and independent of the tort system
CMAJ 2004;170(11):1678-86 86
Your perspective? The vast majority of hospitalised patients in Canada have safe health care, or There are between 10,000 and 23,500 preventable deaths from health care each year in Canada
Leadership System key features Building WILL for change VISION for change Generating IDEAS for an improved system - innovation Resources and permission for change EXECUTING changes to the system
Now.. ACSQHC has an extensive work program, and reports twice a year to Australian Health Ministers Conference for endorsement and local implementation State Quality Officials meet as a Forum of ACSQHC to coordinate and implement Initially formed (and funded) for five years Health Ministers are now working on what the future structures and operational mechanisms should be
AHMC April 2004 agreed: National right patient, right site, right procedure protocol adoption by September 2004 Incident Management system in place by January 2005, using national specifications and classification system 2005 - all public hospitals to have a patient safety risk management plan 2005 - Nationally agreed sentinel event reporting at state level and then contributing to a national annual report A common medication chart in use before June 2006 Pharmaceutical review process in place by December 2006 All patients be provided with Ten Tips for safer health care brochure, at or before hospital admission
In development for AHMC Implementation of national Open Disclosure standard Performance agreements with clinicians minimum data set for safety and quality for management and reporting 10-15 15 year investment plan for safety and quality improvement ongoing affirmation of commitment and leadership
Some accompanying reports: First national chart book for Safety and Quality National standards for credentialling and defining the scope of clinical privileges Discussion paper on setting the human factor standards in health care National guidelines on complaints handling
Elements of the ACSQHC workplan National Taskforces on Medication Safety, Healthcare Acquired Infection and Reducing Fall Injury Building Measurement and its transparency Building Capacity through Education and Research +++
Gary Larson, Far Side, as reproduced in Chase & Stewart, Mistake-Proofing: Designing Errors Out, 1995
Essential Elements for QI Leadership Measurement Improvement
Solutions can be simple - check list Gary Larson, Far Side, as reproduced in Chase & Stewart, Mistake-Proofing: Designing Errors Out, 1995
www.safetyandquality.org safetyandquality@health.gov.au