BRIEFING TO THE INCOMING MINISTER OF HEALTH

DECEMBER 2011

Health Quality & Safety CommissionPO Box 25496Wellington 6146

Telephone: 04 901 6040Email: info@hqsc.govt.nzWebsite: www.hqsc.govt.nz

ContentsIntroduction..........................................................................................................................................1

Background..........................................................................................................................................1

Objectives........................................................................................................................................1

Room for improvement...................................................................................................................1

About quality and safety improvement.........................................................................................4

The Commission’s place in the health and disability sector..........................................................4

The Commission’s work.....................................................................................................................5

Patient and family engagement and partnership........................................................................6

Clinical leadership and partnership..............................................................................................6

Measurement and evaluation........................................................................................................7

Specific projects..................................................................................................................................7

Medication safety............................................................................................................................8

Reportable events...........................................................................................................................8

Infection prevention and control....................................................................................................8

Mortality review...............................................................................................................................8

Surgical checklist............................................................................................................................9

Falls..................................................................................................................................................9

Contestable funds...........................................................................................................................9

Building sector capability for quality and safety..........................................................................9

How we work.......................................................................................................................................9

Moving towards a new future..........................................................................................................10

Measuring our achievements..........................................................................................................11

Funding..............................................................................................................................................12

Board members.................................................................................................................................12

Mortality review committee members.............................................................................................14

Roopu Māori members.....................................................................................................................14

Appendix 1: How New Zealand compares with other countries’ health quality and safety.....15

References........................................................................................................................................17

IntroductionThis briefing provides information about the quality and safety of New Zealand’s health and disability sector and how health outcomes can be improved and value for money increased through better health quality and safety. We discuss why the Health Quality and Safety Commission (the Commission) was established a year ago, along with a brief description of what we are aiming to achieve, how we partner with the sector, what our work programme is, how we are funded and what the future holds.

The briefing also provides information about who is involved in improving quality and safety in New Zealand and provides some international comparisons.

Finally, it introduces our Board members, Chief Executive Officer, mortality review committee members and Roopu Māori members.

BackgroundThe Commission was established as a stand-alone Crown entity in November 2010 in response to concern that only modest improvements in health quality and safety had been achieved at a national level over the previous years. Quality experts argued that a strong mandate to drive quality-related activities, greater co-ordination of appropriate quality interventions at a national level, and strong clinical engagement were pivotal to achieving sustained quality gains and better value for money.

The Commission is also the home of four statutory mortality review committees. The committees review particular deaths to learn how to prevent these in the future. They work within the Commission to inform and enable quality and system improvement within health and other social sectors.

ObjectivesThe Commission’s objectives, as set out in section 59B of the New Zealand Public Health and Disability Act 2000, are to lead and co-ordinate work across the health and disability sector for the purposes of:

monitoring and improving the quality and safety of health and disability support services

helping providers across the health and disability sector to improve the quality and safety of health and disability support services.

“Good quality is less costly because of more accurate diagnoses, fewer treatment errors, lower complication rates, faster recovery, less invasive treatment, and the minimisation of the need for treatment.” (Porter and Teisberg 2006)

Room for improvementNew Zealand’s health system rates well internationally, but there is still significant room for improvement. For example:

for ‘sicker’1 New Zealanders in 2010 (Commonwealth Fund 2011):

o 22 percent experienced a medical, medication or laboratory test error in the past two years

1 ‘Sicker’ New Zealanders is defined in the Commonwealth Fund survey as those who were in fair or poor health, had surgery or been hospitalised in the past two years, or received care for serious or chronic illness, injury or disability in the past year.

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o 51 percent experienced gaps in hospital or surgery discharge, including arrangements for follow-up visits and what medications to take

o 31 percent did not have their prescriptions reviewed and discussed in the past year

in 2001, 12.9 percent of New Zealanders admitted to hospital suffered an unintended adverse event caused in the management of their conditions, rather than the underlying disease and 15 percent of these resulted in permanent disability or death (Davis et al 2001). The cost of events deemed preventable was $590 million (Brown et al 2002)

care and outcomes of treatment are not yet distributed equally in New Zealand. For example, nearly 50 percent more Māori than non-Māori/non-Pacific patients suffer an in-hospital preventable adverse event (after controlling for age, deprivation, admission type, length of stay and sex) (Davis et al 2006)

audits at Counties Manukau District Health Board (DHB) identified that 70 percent of patients had at least one medication error on their inpatient medication chart on admission to hospital, when compared with what the patient actually took in the community (Brkic and Lewis 2007)

between 20 and 43 percent of all electronic discharge summaries undertaken at Waitemata DHB had medication errors; these errors translated into errors in prescriptions for patients and were communicated to the GPs (Lee and Park 2008)

the maternal mortality rate in New Zealand in 2009 was 22 per 100,000 maternities (13.7 in 2008 and 10.3 in 2007). The perinatal mortality rate in 2009 was 11.3 per 1,000 total births (10.6 in 2008 and 10.3 in 2007). One hundred of the 721 perinatal deaths in 2009 are considered ‘potentially avoidable’ as well as a number of the maternal deaths (Perinatal and Maternal Mortality Review Committee 2011).

Many of the adverse events are avoidable and amenable to intervention. The 2009 report of the Ministerial Review Group identified potential savings of about $60 million per annum from reducing preventable adverse events in New Zealand hospitals alone (Ministerial Review Group 2009). More recently a joint DHB/Association of Senior Medical Specialists report Investing in Clinical Leadership for Quality and Safety Improvement (March 2011) estimated achievable productivity gains of:

$10 to $12m from reducing falls in hospitals

$10 to $12m from reducing pressure injuries

$10 to $12m from reducing central line infections (central line associated bacteraemia (CLAB)

$50 to 78m from reducing surgical site infections

$2 to 4m from reducing identification errors.

Examples of successful outcomes from implementation of quality and safety programmes include:

Counties Manukau DHB reduced incidents of infections resulting from CLAB from 6.6 per 1000 line days to 0.9 per 1000 line days over a two-year period with estimated savings of about $200,000 per year

promoting hand hygiene in Starship Hospital’s newborn intensive care unit is paying off, with greater compliance and fewer infections – over the last three years there has

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been a reduction of between 20 and 25 percent in late-onset infections for newborns in the unit

adoption of the World Health Organization (WHO) Safe Surgery Checklist overseas has been shown to result in a 30 percent reduction in patient harm caused by surgery (Haynes et al 2009)

in Scotland over a one- to two-year period, the national quality improvement programme achieved a 73 percent reduction in central line infections, a 43 percent reduction in ventilator-associated pneumonia and a 14 percent increase in ward hand hygiene (Healthcare Improvement Scotland 2011).

There is worldwide acknowledgment that improving quality and safety can be a major contributor to a more sustainable health and disability support system and many countries have established quality and safety agencies. Government agencies have been established in Australia, United Kingdom, Scotland, the United States and last year, New Zealand. There are also many independent quality and safety organisations worldwide.

Common functions of quality and safety organisations are data collection, analysis and reporting, education, quality improvement programme funding and advocacy. Some, such as those in Australia and Scotland, also have regulatory and enforcement functions. Others, including those in the United States, United Kingdom and New Zealand act as catalysts for change, but are not mandated to carry out regulatory and enforcement roles.

In New Zealand, the separation of these two roles was deliberate. Government recognised a potential conflict between the role of holding the sector accountable and the role of facilitating quality and safety improvement. As a result, the Ministry of Health retained responsibility for accountability and standards.

Appendix 1 provides information about New Zealand’s health quality and safety record compared with other countries. New Zealand ranks reasonably well internationally on some indicators eg, fewer patients experience co-ordination problems and more experience positive shared decision-making with a specialist. However, we rank poorly in relation to medical, medication and laboratory test errors – and even in those areas where we rank well, there is significant room for improvement.

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About quality and safety improvement Quality and safety are on a continuum….

Improving quality and safety is not simply about improving performance of individuals working within the system. More important are improvements in the system itself. Some simple examples show the importance of system change in improving safety:

wall-mounted soap dispensers in showers resulted in significant reduction in falls in showers at Lakes DHB Orthopaedic Ward

using red syringe plungers to administer muscle relaxant medications (which make it impossible to breathe unassisted) reduced incidences of awake paralysis at Waikato DHB

introducing a pre-printed decimal point and standardising national medication charts avoids the ‘classic’ ten-fold errors in dose due to illegible prescribing and misunderstandings about dosage.

The Commission’s place in the health and disability sectorNo single organisation has the mandate and power to control and determine quality and safety across the sector. All organisations and individuals involved in providing health and disability services have a role in ensuring quality and safety, and their roles cover a broad spectrum including:

quality and safety assurance activities such as legislation, regulation, standards, certification, auditing and credentialing

a wide range of quality and safety improvement activities supported by a range of organisations including the Commission, Ministry of Health, DHBs, Primary Health Organisations (PHOs), professional groups, clinical networks, private and NGO organisations.

And importantly, all health and disability professionals and workers have an individual responsibility at all times for the quality and safety of their own practice.

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Safety - minimising harm to individuals from treatment in the health and disability system

Quality - increasing the likelihood of desired health outcomes for individuals and populations (and increased participation and independence in the case of disability)

Transformation - making the really big gains in quality and outcomes, and achieving a more sustainable health and disabilty sector through innovation, new ways of organising services and use of technology

doing things right doing the right things doing even better

Given that quality and safety is ‘everyone’s business’, the Commission has an important role to play in maintaining an overview and ensuring integration of the whole quality and safety landscape.

The Commission’s workThe Commission worked with the National Health Board to agree a shared overarching goal for improvement in health services, the New Zealand Triple Aim:

improved quality, safety and experience of care

improved health and equity for all populations

best value for public health resources.

The New Zealand Triple Aim has now been accepted by other key health agencies including the Ministry of Health (including the National Health Board, the IT Board, the National Health Committee, Health Workforce New Zealand), DHBs, Health Benefits Ltd and PHARMAC. This unification of purpose is central to the Commission’s goal of improving the quality and safety of health and disability services across the entire sector.

To achieve the Triple Aim, the Commission works with the sector to:

reduce deaths, harm and consequent wastage from preventable adverse events and errors

reduce unwarranted variation (including the use of ineffective or inappropriate services) and increase the use of effective services

increase value through more efficient service provision

ensure people have efficient access to effective and timely services appropriate to needs

ensure people obtain those services (and only those services) that are right for them, and align with their needs and values.

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Three central elements underpin all our work, both at an operational and strategic level:

patient and family engagement and partnership

clinical leadership and partnership

use of information in a timely and effective way.

Patient and family engagement and partnershipThere is growing evidence demonstrating the importance of partnerships between health services organisations/health professionals, and patients, families, carers and consumers. Studies have demonstrated significant benefits from such partnerships in clinical quality and outcomes, the experience of care, and the business and operations of delivering care. Clinical benefits include fewer deaths (Meterko et al 2010), decreased re-admission rates (Boulding et al 2011), fewer health care acquired infections (Edgcumbe 2009), shorter stays in hospital Di Giola et al 2007), improved adherence to treatment regimes (Arbuthnott and Sharpe 2009) and improved functional status (di Giola et al 2007). Operational benefits include lower costs per case and increased workforce satisfaction rates (Charmel and Frampton 2008).

To achieve these partnerships we are supporting programmes which include:

developing a framework for the Commission and providers to work with patients, family and carers as partners to improve health quality and safety

building the capacity of consumer representative agencies to work with providers as partners

capturing consumer experiences

consumer literacy (initially on medication safety).

An important element of this work is shared, values-based decision-making. Identifying and making decisions about the best health treatment or screening option can be difficult for patients – especially when there is more than one reasonable option, when no option has a clear advantage in terms of health outcomes, and when each option has benefits and harms that patients may value differently.

It is important patients and their families can consider the options from a personal view (ie, how important the possible benefits and harms are to them) and participate with their health practitioners in making a decision.

Research has found that when patients use decision aids (pamphlets, videos or web-based tools) they participate more in the decision-making and are able to reach choices that are more consistent with their values. The effect on actual choices is variable, but the choice of elective surgery is reduced when patients consider the other options (Stacey et al 2011).

The Commission is considering how it can provide frontline staff with proven tools, skills and practical ways to work with patients and their families more effectively.

Clinical leadership and partnership Quality and safety is unlikely to improve unless there is stronger and greater clinical leadership and clinical engagement throughout the sector. The Commission forms partnerships with clinical leaders and champions to ensure our work is grounded in the most up-to-date evidence-based knowledge, translated into tools, techniques and methodologies, and promoted and implemented across the sector.

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Strong clinical leadership has been engaged for each of our key projects and we are developing a broad network of clinical leaders and expert advisors who can be called on as required for specific programmes, engaged in broad discussions about the Commission’s work and direction, and provide leadership in the sector for implementation.

The Commission also has a key role in building leadership capability for quality and safety improvement. We are establishing links with the National Health Services Institute for Innovation and Improvement (England) and the Institute for Healthcare Improvement (United States), which have a range of programmes to support implementation of change and building capacity.

Measurement and evaluation The use of information and knowledge in a timely and effective way is vital to sustaining a culture of quality and safety in health care and to the effectiveness of initiatives to improve quality and safety. The Commission is charged with providing a clear picture of sector performance over time through national and international benchmarking. We need to provide information that shows managers and clinicians where they are performing well, and where improvements can be made. It is also important to know whether programmes are achieving their outcomes. Establishing a small, meaningful and relevant set of national quality and safety indicators is a priority, so we can use these to monitor progress and identify priorities for action.

Information is only helpful if it is available at the right time and in a form that is readily understood. It must make sense within the context of the clinician/patient relationship or the services/community relationship. In New Zealand, a lot of data are collected for multiple purposes. Our role is to focus on turning the key elements of these data into timely and accessible information that brings greater understanding and wisdom to both clinicians and consumers.

We are progressing:

the first report against national and international measures and indicators of quality and safety. This will provide the starting point for time series information to track performance and demonstrate and motivate success across the sector

the first health care variation report. This will identify unwarranted health care outcomes and practices. Variation reporting is designed to encourage discussion by clinicians about good practice and contributes to consumers getting appropriate treatment regardless of who their practitioner is or where they live

the use of trigger tool surveillance to assist in identifying harm and injury to patients and to help organisations to track and learn from their behaviours over time

the use of quality reports (also known as quality accounts) which requires leaders of an organisation to consider the quality of their services, their priorities for improvement, the actions they intend to take to secure improvements, and to make this information available to the public

evaluating the effectiveness and efficiency of our key programmes.

Specific projectsThe Commission inherited several existing health quality and safety projects when it was established. These projects form the core of our current project work. Many of the projects were focused on the hospital sector and we are increasingly widening our scope to include the broader sector (including primary care, aged care and disability)

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Medication safetyIn order to reduce preventable medication errors and consequently reduce harm and cost and increase patient confidence, we are leading the national Medication Safety Programme. There is potential, over time, for substantial reductions in patient harm and in costs to free up valuable resources. Our initial focus is on implementing:

the national adult medication chart which is a simple but effective way of reducing medication errors

the medicine reconciliation process which ensures patient medicines are checked at critical handover times, such as when patients are admitted to, transferred within or discharged from hospital

the eMedicines programme in partnership with the National Health IT Board (this is a cornerstone of the wider e-health programme).

Reportable eventsWe have worked with the sector to develop and agree a national policy for reporting and managing health care incidents which will assist providers to identify and address systemic issues in their own organisations that lead to medical errors.

Our annual serious and sentinel events report assists in identifying and promoting understanding of systemic quality and safety issues and provides New Zealand case studies of successful interventions.

Infection prevention and controlIn order to reduce the harm and cost of avoidable infections acquired during health care, we are leading work on infection control including:

the national Hand Hygiene Programme

the CLAB Programme

the Surgical Site Infection Surveillance Programme.

Mortality reviewThe Commission’s four mortality review committees report annually on mortality and morbidity, and identify priorities for preventing such deaths and harm in future.

The Child and Youth Mortality Review Committee and the Family Violence Death Review Committee also work locally and regionally to find and implement interagency solutions to some of the priority issues highlighted by their work.

Current work of the committees includes:

Child and Youth Mortality Review Committee: implementing awareness campaigns and prevention resources for sudden unexpected death in infancy (SUDI), and addressing youth suicide in the Pacific community

Perinatal and Maternal Mortality Review Committee: identifying and targeting perinatal deaths that can be classified as ‘potentially avoidable’

Family Violence Death Review Committee: implementing a network of regional local review panels and reviewing family violence deaths from 2010 and 2011

Perioperative Mortality Review Committee: publishing its inaugural report on perioperative mortality ie deaths after an operative procedure or while under the care of a surgeon in hospital.

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Surgical checklistIn order to reduce avoidable surgical errors (for example wrong patient, site or procedure and retained instruments or swabs) and to improve teamwork and communication in the operating room (which are very important factors determining outcome) the Commission is working to improve the effectiveness of the use of the WHO Safe Surgery Checklist. The checklist is widely used in New Zealand, but the engagement of clinicians in its use is variable (as it is in most other countries).

We are working with Dr Atul Gawande’s unit at the Harvard School of Public Health to implement an initiative to ensure the checklist is used ‘every time, in every theatre, effectively’. Dr Gawande led the development of the checklist and has been running a parallel initiative in South Carolina. This work will reinforce and interlink with the ‘productive theatre’ work of the Ministry of Health.

FallsIn order to reduce the number and impact of falls in inpatient, residential and community settings, the Commission is working with the DHB shared services organisation to gather information and scope the work required.

Contestable funds There are many exciting and effective local initiatives in different hospitals, practices, and other health and disability organisations. Identifying and advancing those that have national potential has long been recognised as an important but challenging opportunity to reduce harm and make the best use of the health dollar.

The Commission has therefore provided seed funding for a selected number of health and disability providers to test and trial new ideas. Selected providers cover a broad range of services including disability support, older people, primary care and the community sector. Evidence of successful initiatives will be shared with the wider sector.

Building sector capability for quality and safety The Commission aims to assist the spread of innovation and good practice, and to introduce the sector to leading local and international quality and safety initiatives and experts.

Education and relevant skills training is fundamental to this. Initially, we have worked with other organisations to support their programmes, and we plan to hold at least one quality forum each year. We are currently developing a comprehensive plan for building sector capability into the future, focusing on the use of improvement tools, and on creating a learning system through which frontline staff improve their knowledge and gain tools and resources that can be applied across programmes to improve the quality and safety of their practice.More detail about our programmes can be found in our 2011–2014 Statement of Intent which is attached and is also available at www.hqsc.govt.nz.

How we workWe are a small agency and rely heavily on partnerships within the health and disability sector to provide expertise, implement programmes and change the quality and safety culture of our health and disability services.

We are determined to achieve the substance of change rather than merely adding to the already excessive rhetoric in this area. This requires participation in all steps of the relevant health and disability processes. Change must be successfully and affordably implemented and it must be enduring. The focus must remain on the objectives of saving lives, reducing harm and improving value for the available resource (our Triple Aim).

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The Commission puts a great deal of emphasis on collaboration and co-ordination between different parts of the sector – New Zealand is a small country and we all have to work together to the agreed common end.

Of particular importance are our partnerships with clinical leaders, consumers and consumer groups and a developing partnership with Māori. We also have strong international links, so that we are well-connected to innovation, evidence and advice from our colleagues overseas.

Moving towards a new futureThe Commission’s initial focus is necessarily on ‘first order changes’ aimed at improving patient safety and service quality directly. This is reflected in our programmes to:

ensure we reduce harm

identify and address unwarranted variation

build a culture of constant examination and improvement around ‘doing the right thing, right, first time’.

By focusing on this work, we will continue to reduce harm and achieve better value for money from our services.

In addition the Commission needs to provide the direction and co-ordination within the sector to:

develop and support sector leadership

develop a culture where partnerships with patients and families are the norm and where patients and their families are able to make the values-based decisions that mean they get those treatments (and only those) that they actually need and want

provide an overview of the whole health quality and safety landscape, make sense of what is happening and set the quality and safety agenda

be a reliable source of information of quality and safety for the sector and develop a sector where improvement is information driven

provide commentary and help the sector have conversations about the difficult issues that underpin substantial wastage in health care so that we can make changes to align our processes to the real needs and values of our patients

provide expert assistance to organisations and people implementing quality and safety change programmes

reduce fragmentation and duplication by sharing ideas and information nationally and providing a more systematic way to learn from each other.

Over the next few years our focus on these broader roles will increase, although our work will always be underpinned by effective programmes to improve the safety and quality of our health and disability services. Change occurs at the workface by participation in effective initiatives to improve practice, not by rhetoric. It is by demonstrating to practitioners and administrators that improving quality is both possible and worthwhile that we can best change the quality and safety culture.

Our longer term strategy must also encompass ‘second order change’. If New Zealand is to make the really big gains in quality and outcomes and achieve a financially sustainable health and disability sector, we need to actively consider different ways of organising health services.

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Clearly greater integration is needed within health and between health and social services. This implies stronger partnerships with patients, families and communities, a far greater emphasis on shared values-based decision-making between patients and their providers, increased use of technology (including information technology) and a much stronger focus on facilitated networks of care for people with chronic needs.

There are already good examples of the use of technology to improve health outcomes of people with chronic needs (at a lower cost). These include the use of e-therapies for people with mild to moderate mental health problems, and the electronic depression management programme which involves use of computers, telephone help-lines and text messaging.

Emerging technology and methods of communication have enormous potential to improve outcomes and generate saving in the management of chronic illness. The key will be the greater empowerment of patients to engage more effectively in their own care, while ensuring access to the support they really need.

For example, in one programme in the United States, people with congestive heart failure are provided with scales that send their weight wirelessly to a nurse. In one instance when a woman put on a significant amount of weight in 24 hours, the nurse was able to ring her within 30 minutes of getting the wireless weight reading and give her instructions on increasing her medications, thus avoiding further deterioration and possible hospitalisation. Shifting health care from hospitals to the community in this way reduces costs and improves the patient experience.

The Commission will maintain an overview of international and national innovations to ensure it is an effective catalyst for change. We are committed to ensuring New Zealand continues to have a world-class, innovative, patient and family/whānau centred health and disability support system with continually improving quality and safety.

Measuring our achievementsOver the next few years we will develop a clear picture of quality and safety in the sector, and of the impacts of our work. All of our key programmes will be evaluated and monitored. This will include an assessment of each programme’s impact on:

reducing avoidable deaths, harm and wastage

improving health outcomes

improving equity and reducing inappropriate variation

improving value for money.

We will also measure consumer satisfaction with their health and disability care experiences and treatments.

Currently we are evaluating the Medication Safety Programme. We will measure whether the programme is achieving its long-term goal of reducing potential and actual adverse drug events (ADEs) resulting in improvements in:

ADE associated morbidity and mortality

ADE associated health care costs

medication safety and patient confidence in the use of medicines.

Our evaluation activity along with our time-series reports against indicators of quality and safety will assist the Ministry of Health with its 2015 report back to Cabinet on the impact of the Commission’s activities.

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FundingThe Commission receives annual funding of $14.5 million for its activities. Fifteen percent is allocated to operational support costs and 85 percent to programme costs. We do not currently receive any third-party funding.

Board membersProfessor Alan Merry (Chair)

Professor Alan Merry is Head of the University of Auckland’s School of Medicine. He is a practising cardiac anaesthetist and chronic pain specialist, and works with patients in routine surgical settings (in public and in private), in life-threatening medical emergencies and in managing chronic illness. He currently chairs the Quality and Safety Committee of the World Federation of Societies of Anaesthesiologists, and worked with the WHO as the anaesthesia

lead of the Safe Surgery Saves Lives initiative. He is involved with a follow-on project with these (and other) organisations to improve the safety of anaesthesia world-wide through enhanced standards, technology and education. Professor Merry has a long-standing interest in safety and quality in health care: he co-chaired the New Zealand Medical Law Reform Group in the 1990s, and has conducted research into various aspects of safety in anaesthesia and surgery. He co-authored the book Safety and Ethics in Healthcare, A Guide to Getting it Right.

Dr Peter Foley (Deputy Chair) Dr Peter Foley brings a valuable mix of experience to this role. He is experienced at dealing with health systems at a ‘big picture’ level, while also continuing to work as a GP, based in Hawke’s Bay, where he is the DHB Chief Medical Officer – Primary Care. Dr Foley is the immediate past Chair of the New Zealand Medical Association (NZMA) – a role which required high-level abilities in planning and managing systems, while working in close affiliation

and alignment with other key medical organisations such as the Royal New Zealand College of General Practitioners and the New Zealand Council of Medical Colleges. He was recently conferred an NZMA Fellowship in recognition of many years spent advancing health policy in New Zealand. He has a particular interest in the Commission’s future aged care work.

Mrs Shelley Frost A registered nurse with significant experience in primary health care, Shelley Frost is the current Deputy Chair and Executive Director (Nursing) of General Practice New Zealand, and also a member of the General Practice Leaders’ Forum, and the Canterbury General Practice Group. Her involvement in those roles builds on her strong clinical governance and leadership skills.  She is the Director of Nursing at Pegasus Health, an executive role with responsibility for

the provision of professional and clinical nursing leadership.  She is also Deputy Chair of the Canterbury DHB’s Clinical Board, and a trustee of Partnership Health Canterbury PHO.

Dr David Galler

Dr David Galler is an intensive care specialist at Middlemore Hospital in Manukau City.  Prior to this he was Principal Medical Advisor to the Minister of Health at the Ministry of Health, and Clinical Director of Acute Care at Middlemore Hospital. A past President of the Association of Salaried Medical Specialists, Dr Galler has worked extensively on quality and safety issues in recent years through a close involvement in the Ministry of Health’s Quality

Improvement Committee – the predecessor of the current Commission.

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Dr Peter JansenDr Peter Jansen, of Ngati Raukawa descent, is a senior medical advisor to ACC. He has extensive experience as a teacher, researcher and health management advisor for Mauri Ora Associates, experience as a GP in Papakura and Whangamata, and was a former Medical Director of Boehringer Ingelheim (NZ) Limited, a multinational pharmaceutical company. He has published a number of papers relating to cultural competence in health care,

and led the development of guidelines on Cultural Competence for health-related organisations in New Zealand.  He received the award of Distinguished Fellow of the Royal New Zealand College of General Practitioners for his work in this area. Dr Jansen’s previous appointments have included deputy chairperson of Counties Manukau DHB and a board member of MidCentral Health.  He was also an inaugural director of ProCare IPA, a director of Quality Health NZ (formerly the NZ Council of Healthcare Standards), and was clinical director of Te Kupenga o Hoturoa PHO.

Mr Geraint MartinGeraint Martin has more than two decades of experience in health management, and is the current CEO of Counties Manukau DHB, a role he has held since 2006. He has extensive experience in key health governance roles – and has held posts as Director of Health and Social Care Strategy for the Welsh Assembly Government and Chief Executive of Kettering General Hospital in Northamptonshire. Mr Martin has developed and implemented

clinical quality improvement programmes in both the UK and New Zealand.  At Counties Manukau DHB he leads the Clinical Leadership Team which is developing whole-of-system changes to the way hospitals work. He has established a Centre for Health Services Innovation led by New Zealand's first chair in health innovation and improvement. He also helped lay the foundations of the "Saving 100 lives” campaign in Wales, which used clinical quality improvement across an entire national health care system to drive patient safety.

Mrs Anthea PennyAnthea Penny is a qualified health professional, an experienced chief executive in the New Zealand health sector and a management consultant. She is director of R H Penny Ltd, Australasia, and Australasian agent for the NHS Institute of Innovation and Improvement, (Service Transformation) responsible for the NHS Institute’s commercial affairs and relationships in New Zealand and Australia. She is also the inaugural recipient of the 2004 New Zealand Institute of Health

Management Silver Fern Award for Excellence in Health Service Management. Since 1993, Anthea Penny has worked as a management consultant, with national and regional funders and service providers of health care, aged care and rehabilitation in New Zealand and Australia. Her main role has been to review and improve organisational performance and to develop health policy and strategy across the service delivery spectrum.

Chief Executive Officer: Dr Janice Wilson

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Mortality review committee membersPerinatal and Maternal Mortality Review Committee

Perioperative Mortality Review Committee

Child and Youth Mortality Review Committee

Family Violence Death Review Committee

Professor Cynthia Farquhar (Chair)Professor Lesley McCowanDr Vicki CullingDr Stephanie PalmerMrs Anja HaleDr Beverley LawtonMs Susan BreeDr Alec EkeromaDr Margaret MeeksDr Graham Sharpe

Professor Iain Martin (Chair)Dr Digby Ngan KeeDr Jonathan KoeaMs Teena RobinsonDr Philip HiderDr Catherine (Cathy) FergusonDr Leona WilsonDr Anthony WilliamsMs Rosaleen Robertson

Dr Nicholas Baker (Chair)Dr Anganette HallProfessor Edwin MitchellDr Sharon WongMs Susan MatthewsMs Anthea SimcockMr Eruini GeorgeMr Paul Nixon

Associate Professor Julia Tolmie (Chair)Associate Professor Dawn ElderMs Ngaroma GrantMs Miranda RitchieProfessor Barry TaylorMs Fia Turner-TupouJudge Paul von DadelszenAssociate Professor Denise Wilson

Roopu Māori members Tu Williams (Chair) Rees Tapsell Riripeta Haretuku Leanne Te Karu Rachel Thompson

Roopu Māori provides advice to the Board and Chief Executive of the Commission on strategic issues, priorities and frameworks from a Māori world view and identifies key quality and safety issues for Māori patients and organisations.  Advice from this group can assist in the gathering and interpretation of data on quality and safety and also prioritise or shape new programmes to ensure the Commission’s aim to improve health and equity for all populations can be achieved.

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Appendix 1: How New Zealand compares with other countries’ health quality and safetyThe most recent Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries (2011) focused on people in fair or poor health, who had undergone surgery or been hospitalised in the past two years, had received care for serious or chronic illness or had an injury or disability in the past year. The survey covered Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom and the United States.

The survey showed that New Zealand ranks reasonably well internationally on some indicators, eg, fewer patients experienced co-ordination problems in the past two years, and more experienced positive shared decision-making with a specialist. It ranks poorly in relation to medical, medication and laboratory test errors. However, even in those areas where we rank well, there is significant room for improvement.

Area measured Percentage Ranking out of 11 countries measured (best = 1st)

Experienced co-ordination problems in the past two years (Test results/records not available at time of appointment, doctors ordered test that had already been done, providers failed to share important information with each other, specialist did not have information about medical history, and/or regular doctor not informed about specialist care).

30% 3rd

Experienced gaps in hospital or surgery discharge in the past two years (did not receive instructions about symptoms and when to seek further care, know who to contact for questions about condition or treatment, receive written plan for care after discharge, have arrangements made for follow-up visits and/or receive clear instructions about what medicines they should be taking).

51% 5th

Experienced a medical, medication or laboratory test error in the past two years.

22% 9th

Did not have their prescriptions reviewed and discussed in the past year.

31% 6th

Experienced a positive shared decision-making experience with specialists (Specialist always/often gives opportunities to ask questions about recommended treatment, tells you about treatment choices and involves you as much as you want in decisions about your care).

72% 3rd

The 2011 Organisation for Economic Co-operation and Development (OECD) Health at a Glance report notes that for procedural or post-operative complications New Zealand has rates higher than the OECD average. New Zealand is in the top four for ‘foreign body left in’ during procedure, the top three for accidental puncture or laceration and in the top three for postoperative sepsis.

On the other hand, admission rates for asthma and Chronic Obstructive Pulmonary Disease (COPD) have reduced significantly over the past few years and New Zealand has the second lowest rate of avoidable admissions for uncontrolled diabetes.

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International comparisons relevant to the work of the Commission’s mortality review committees.

Among the industrialised nations, New Zealand has the highest rate of death from SUDI. The burden of this problem falls disproportionately in the Māori community and amongst families living in deprived circumstances. In New Zealand, the total mortality rate is 1.1 deaths per 1000 live births. The Māori rate is at 2.3 deaths per 1000 births while the rate for other ethnicity is 0.52 deaths per 1000 births.

International comparisons show that New Zealand has the highest rates of youth suicide in the OECD for both men and women aged between 15 and 19 years according to the OECD 2009 report Doing Better for Children. Caution needs to be taken when making international comparisons of suicide rates because many factors affect the recording and classification of suicide and can result in undercounting of suicide in other countries. However, it is a significant concern that too many young people die by suicide in New Zealand.

Results of a 2003 UNICEF study of child maltreatment deaths in rich countries in the 1990s showed that New Zealand had the third highest child maltreatment death rate in that period (1.2 deaths per 100,000 children under the age of 15 years).

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DiGiola A, Greenhouse P, Levison T. 2007. Patient and family-centred collaborative care: An orthopaedic model. Clinical Orthopaedics and Related Research 463(13-19).

Arbuthnott A, Sharpe D. 2009. The effect of physician-patient collaboration on patient adherence in non-psychiatric medicine. Patient Education and Counseling 77(1): 60-7.

DiGiola A, Greenhouse P, Levison T. 2007. Patient and family-centred collaborative care: An orthopaedic model. Clinical Orthopaedics and Related Research 463(13-19).

Charmel P, Frampton S. 2008. Building the business case for patient-centred care. Healthcare Financial Management March 62(3): 80-5.

Stacey D, Bennett CL, Barry MJ, et al. 2011. Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews 10(CD001431). DOI: 10.1002/14651858.CD001431.pub3.

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OECD (2011), Health at a Glance 2011: OECD Indicators, OECD Publishing.http://dx.doi.org/10.1787/health_glance-2011-en.

OECD (2009) Doing Better for Children. Downloaded from www.oecd.org/els/social/childwellbeing on 7 December 2011.

UNICEF. 2003. A league table of child maltreatment deaths in rich nations. Innocenti Report Care. No. 5.September. UNICEF Innocenti Research Centre, Florence. The United Nations Children’s Fund, 2003.

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