“ you wouldn’t be dead for quids!” 5 december 2011 chris baggoley 7th health services and...
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7th Health Services and Policy Research Conference
““You wouldn’t be dead for quids!”You wouldn’t be dead for quids!”
5 December 20115 December 2011
Chris BaggoleyChris Baggoley
Aged Care shortage chokes hospitals
Source: The Age, Thursdasy June 2, 2011
HEALTH REFORM - Overview
Better coordinated and localised delivery of health services
Changed responsibilities between Commonwealth and State Governments
More Sustainable Financing
New National Institutions
Greater Transparency and accountability
BENEFITS OF NATIONAL HEALTH REFORM
An integrated and high performing health system
Easier for patients to move around the health system and receive the care they need, when and where they need it
A focus on prevention and primary health care will keep people well and out of hospital
Increased transparency on the performance of health services at a local level
IMPROVED ACCESS TO HOSPITALS
National Emergency Access Target 90% of all ED patients across all triage categories will be admitted, referred or discharged from Emergency
Departments within four hours
Elective Surgery Target Patients to be treated within clinically recommended time will be raised from 95% to 100% by 2015
Implementation timeframe will be extended in smaller states by one year to 2016
MAJOR EMPHASIS ON PERFORMANCE AND
ACCOUNTABILITY
New Performance and Accountability Framework
National Health Performance Authority (NHPA)
Hospital Performance Reports and Health Communities Reports
Emergency doctor:
We can't cope !
Hospital ‘overcrowded, overwhelmed’
The Age – 6 October 2011
Wait at hospitals is a test of patients
Source: Herald Sun, Thursday June 2, 2011
Literature Review
“The priority is not simply devising yet more standards and indicators, but
working on the nuts and bolts of how we turn measurement for improvement into
tangible change in practice”
Source: Scott, I & Phelps G
“Measurement for Improvement:
Getting one to follow the other” IMJ 2009, 39, 347-351
Literature Review
“The available evidence suggests that targets face resistance at local level if they are imposed
on those who must implement them. Mechanisms that foster participation and a sense
of ownership are an important element of a target based strategy”
Source: Ernst, K., Wismar, M et al Chapter 4
“Improving the Effectiveness of Health Targets”
In “Health Targets in Europe: Learning from Experience”,
European Observatory on Health Systems and Policies, Observational Studies Series No 13, 2008
Literature Review
“A target should be sufficiently challenging to stimulate new and
better ways of doing things rather than simply waiting for nature to take its
course”
Source: McKee, M Chapter 3: On Target?
Monitoring and Evaluation in
“Health targets in Europe: Learning from
Experience” European Observatory on Health Systems and Policies 2008, Observations Studies Series No 13
Literature Review
“The most difficult phase of redesign is not identifying issues or designing new
solutions; it is implementing those solutions and embedding the redesigned
model into core business processes”
Source: O'Connell, T, Ben-Tovim, D., McCaughan B, and McGrath, K
“Health services under siege: the case for clinical
process redesign” MJC 2008, 188, S9-S13
Literature Review
86 cases of hospital process redesign
that have not led to consistent
improvements in either patient
outcomes or system performance
Scott, I, Wills, R-A et al “Impact of hospital-wide
Process redesign on clinical outcomes: a comparative study of
internally versus externally led intervention” BMJ 2 & Q: 2011: 20: 539 - 548
LITERATURE REVIEW
Risks of performance targets
“Hitting the target but missing the point”, ie quantity not quality
Alienation of key stakeholders where there is a lack of consultation, planning and communication
“Gaming” including cherry picking of patients and manipulating data
Source: Expert Panel Review of Elective and Emergency Access
Targets under the National Partnership Agreement in Improving
Public Hospital Services: Supplementary Annexure. Report to COAG: August 2011 pp 15-16
Literature Review
Emergency Department Targets
Strong evidence linking ED overcrowding and access block to poorer patient outcomes in Australia
Similar association in Canada, USA and UK
ED overcrowding and access block contribute to
20 - 30% excess mortality rate
Also contribute to prolonged inpatient length of stay
Source: Expert Panel Review of Elective and Emergency AccessTargets under the National Partnership Agreement in Improving
Public Hospital Services: Supplementary Annexure. Report to COAG: August 2011 pp 17-18
Literature Review
Elective Surgery Targets
Problems with Patient categorisation
Variation in use of urgency categories across surgical specialties and between hospitals
Variation according to socio-economic status of patient and remoteness from health services
Source: Expert Panel Review of Elective and Emergency AccessTargets under the National Partnership Agreement in Improving
Public Hospital Services: Supplementary Annexure. Report to COAG: August 2011 p.23
Access Block and the Introduction of
The Four Hour Rule Program in 4 Western Australia Hospitals
Monthly performance against the Four Hour Rule Program in
Western Australia **July 2008 – April 2011
Elective Surgery Urgency Categories
Cat 1 Admission within 30 days desirable for a condition that has the potential to deteriorate quickly, to the point
that it may become an emergency
Cat 2 Admission within 90 days desirable for a condition causing some pain, dysfunction or disability,
but which is not likely to deteriorate quickly or become an emergency
Cat 3 Admission within 365 days for a condition causing minimal or no pain, dysfunction or disability,
which is unlikely to deteriorate quickly and which does not have the potential to become an emergency
Source: Expert Panel Review of Elective and Emergency AccessTargets under the National Partnership Agreement in Improving
Public Hospital Services: Supplementary Annexure. Report to COAG: August 2011 p. 56
Clinical PriorityCategory: NSW
Cat 1 Admission within 30 days desirable for a condition that has the
potential to deteriorate quickly to the point that it may become
an emergency
Cat 2 Admission within 90 days desirable for a condition which is not
likely to deteriorate quickly or become an emergency
Cat 3 Admission within 365 days acceptable for a condition which is
unlikely to deteriorate quickly and which has little potential
to become an emergency
Cat 4 Patients who are either clinically not ready for
admission (staged) and those who have deferred admission for
personal reasons (deferred) (Not Ready for Care)
Source: Expert Panel Review of Elective and Emergency AccessTargets under the National Partnership Agreement in Improving
Public Hospital Services: Supplementary Annexure. Report to COAG: August 2011 p. 57
NSW
VIC
QLD
WA
SA
TAS
ACT
NT
Cat 1
26%
27%
37%
28%
32%
39%
30%
42%
Cat 2
30%
48%
45%
36%
35%
41%
50%
39%
Cat 3
43%
26%
18%
36%
34%
20%
20%
18%
Percentage of patients byUrgency category (2009-10)
Source: Expert Panel Review of Elective and Emergency AccessTargets under the National Partnership Agreement in Improving
Public Hospital Services: Supplementary Annexure. Report to COAG: August 2011 p. 56
Guiding Principles
1. Targets and the changes required to meet them will require commitment right across the health and hospital system
2. Hospital executives will need to work in partnership with clinicians to achieve sustainable change
3. Clinical engagement and clinical leadership will be essential if the targets are to be met
4. Targets must drive clinical redesign with a whole-of-hospital approach
5. Clinical redesign must ensure patient safety and enhance quality of care
Source: Expert Panel Review of Elective and Emergency AccessTargets under the National Partnership Agreement in Improving
Public Hospital Services: Supplementary Annexure. Report to COAG: August 2011 p.13
Guiding Principles
6. Definitions to be clear and consistent across all jurisdictions
7. The performance of jurisdictions is not comparable
8. Progress towards the targets needs to be linked with continual monitoring of safety and quality performance indicators and audit
9. The impact of targets on demand needs to be monitored and early strategies developed to ensure achievements are
sustainable
10. Quality of training is maintained
Source: Expert Panel Review of Elective and Emergency AccessTargets under the National Partnership Agreement in Improving
Public Hospital Services: Supplementary Annexure. Report to COAG: August 2011 pp 14-15
A Consumer ViewA Consumer Viewof Health Careof Health Care
“I have a right to safe and high quality care”
This means: To be free of being infected by my hospital or health
worker To be given the right medications at the right time To be assessed for the risk of VTE To undergo the correct procedure, operation, test, x-ray To be rescued if my condition unexpectedly deteriorates
Australian Safety and Quality Goals for Health Care
•Potential areas for Goals– Healthcare Associated Infections– Medication Safety– Partnering with patients and consumers– Appropriateness of care
- Cardiovascular Disease (Stroke care and Acute Coronary
Syndrome) - Diabetes
Standard 7Blood and Blood
Products
Standard 10Preventing Falls and
Harm from Falls
The NSQHS Standards
Standard 1Governance for Safety and
Quality in Health Service Organisations
Standard 2Partnering withConsumers
Standard 4Medication Safety
Standard 3Healthcare AssociatedInfections
Standard 8Preventing and
Managing Pressure Injuries
Standard 9Recognising and
Responding to ClinicalDeterioration in Acute
Health Care
Standard 5Patient Identificationand ProcedureMatching
Standard 6ClinicalHandover
National Safety And QualityStandards
Identify issuesand risks
Health Sector Programs
Data andinformation
Accreditation – Measurement
of systems,actions and data
Solutions, actionstools and supports
ACSQHC: The Australian Quality Improvement Cycle
• Antimicrobial Resistance
Time Line of the Rapid Rate of Resistance
Source: Gottlieb T. Nimmo G. Med J Austr 2011. 194:281-3
Development of a National AMS Program
Activities will include:
Undertaking a formal gap analysis to identify deficits or areas to be prioritised in the national program.
Consultation with jurisdictions, clinicians, private sector, and primary care providers to develop a national plan with key stakeholders including: Evaluation of existing resources available. Monitoring national and international evidence regarding AMS Developing mechanisms for implementation of AMS nationally that allows for harmonisation of the key factors and local implementation such as on-line workshops based on the formal gap analysis
Steering Committee
Chair – Chief Medical Officer
Members – Chief Execs
ACSQHC Prevention Programs
• Hand Hygiene
• Hospital AMS
• Infection control guidelines
• Clinical capacity
• National Surveillance
NHMRC1. Infection control
guidelines2. AMR Advisory
Committee- Community acquired• MRSA• Beta lactamases• E coli- Research priorities
PBAC/TGA•Pharmaceutical Benefits Advisory Committee
•Regulation
NPS Campaigns
• Community prescribers
• Mass audience
Animal
Agriculture
The role of this plan would include:• implementing a comprehensive national resistance monitoring and audit system• coordinating education and stewardship programs• implementing infection prevention and control guidelines• expanding funding to support research into all aspects of antibiotic resistance• reviewing and upgrading the current regulatory system applying to antibiotics• undertaking community and consumer campaigns
Food authorityProfessional
organisations
Australian AMR Plan
Choice of Choice of antibioticantibiotic
Infection control
Accreditation Data
Programs
Antimicrobial ResistanceQuality Improvement cycle
Accreditation
DoHA S & T NHPA
NAUSP
Surveillance
AGAR DUSC
NAUSP PHLN BEACH
NPS
ACSQHC
Agencies
AICA
NHMRC
Research
Translation
NPS AMSTGA
PBACTGx
ACSQHC
TGx Uni, Colleges
NHMRC ACSQHC
NPS