CLINICAL GOVERNANCE A PERSONAL POINT OF VIEW

1. CLINICAL GOVERNANCE A PERSONAL POINT OF VIEW • By • DR BILL BERESFORD

2. “CLINICAL GOVERNANCE IS THE FRAMEWORK THROUGH WHICH ORGANISATIONS AND THEIR STAFF ARE ACCOUNTABLE FOR THE QUALITY OF PATIENT CARE” • NHS Commission of Health Improvement 1999 • - “ a response to Bristol Royal Infirmary Inquiry”

3. TODAYS PRESENTATION • Personal Profile • Understanding Inquiries • King Edward Memorial Hospital • Bundaberg Base Hospital • Lessons from Rebuilding • Special Problems for Rural Areas

4. DR BILL BERESFORD PERSONAL PROFILE • Qualified medicine 1968 & initial specialty training paediatrics then tropical medicine • 1977-79 GP private practice Narrabri, NSW • 1979-84 SMO Derby & Medical Coordinator Kimberley RFDS • 1984-88 Medical Director all WA non-teaching hospitals • 1988-89 Assist. Commissioner of Health • 1989-2000 & 2002 -2005 initially Medical Superintendent then A/CEO Royal Perth Hospital • 2000-2002 A/CEO KEMH & PMH • 2005 – retired July. A/DMS Bundaberg Sept – July 2006 • 2006- Clinical CEO Rockhampton plus clinical leadership role for 9 Health Districts

5. UNDERSTANDING THE REPORTS • Royal Commissions are run by Lawyers operating within strict boundaries set by Politicians • Inquiries are conducted in an environment of “Trial by Media” • Staff are subject to inquisitorial examination in a culture of blame • Governments in order to be seen to take action seek scapegoats prior to inquiry findings • Learned papers are written by those with second hand knowledge – based predominantly on the inquiry reports

6. KEY FACTORS LEADING TO ROYAL COMMISSIONS Bristol KEMH Bundaberg Failure of credentialling - - + OT doctor + - + No performance review + + + No critical incident system + + + No response to Incidents + + + Executive distant from Staff + + + No management response + + + Fear of loss of service + - + Budget pressures + + + No review clinical indicator + - + Whistleblower + ? +

7. KING EDWARD MEMORIAL HOSPITAL (KEMH) • WA’s only tertiary Women’s Hospital • Mid 90’s Board of Management amalgamated Princess Margaret Hospital for Children & KEMH – new CEO • 1998 – single Metropolitan Board of Management – new CEO • Jan 2000 – CEO sacks Executive • Clinical staff at both PMH & KEMH vote no confidence in CEO • Childs & Glover Report into KEMH • CEO whistleblower • Sept 2000 CEO replaced

8. CHALLENGES ON ARRIVAL AT KEMH & PMH • Douglas Inquiry into KEMH – review of 105,000 O & G cases • Public Accounts Committee investigation into Trust Accounts at PMH • H.I.C. investigation into Medicare billing practices at PMH – outpatients privatised in early 90’s • A.C.C. investigation into alleged trust account frauds at PMH

9. STATUS OF KEMH & PMH ON ARRIVAL • Executive under siege and isolated – no records available • Resignation / transfer of many key staff • Residual staff angry/ depressed/ under pressure but united against executive • Breakdown of all quality and governance systems • Budget in disarray – private consulting firm managing finance • Negative media daily • Loss of public confidence in organisation

10. BUNDABERG BASE HOSPITAL • District Hospital providing service to Bundaberg Health District (pop. Approx. 100,000) • Administered from Brisbane as part of Central Area Health Service – centralised HR/ IT/ Finance/ Capital & laboratories • Years of fiscal restraint & unrealistic waitlist targets • Executive remote from staff • Disagreement DM with key clinical staff – resignations • IMGs recruited to provide surgery • No effective clinical governance systems • Whistleblower ICU nurse manager

11. LEAD UP TO ARRIVAL IN BUNDABERG (5MONTHS POST-CRISIS) • Executive stood down • Review by DDG and other Dept of Health Officials • Premier intervenes & special deal for victims • Acting DM/ rotation of EDMS(6) and DONS (3) • Morris Inquiry commences, ceases because of bias & replaced by Davis Inquiry • Police & Coronial investigation into deaths commences • Min. Health/DDG/ CHO and other Headquarter staff dismissed • Continuous adverse publicity local, national and international media

12. STATUS ON ARRIVAL IN BUNDABERG • Hospital recovery commenced thanks to A/DM • Breakdown of existing clinical governance and management systems • Management distracted from recovery by demands of Inquiry & investigations & management of 2000 + potential Patel cases • Loss of many Senior & Junior medical staff & difficult to recruit • Morale of remaining staff poor & staff divided • Continued bad media daily

13. KEY ACTIONS IN REBUILDING FOLLOWING A DISASTER • Re-establish Governance systems • Improve internal communications • Manage external environment • Manage the Inquiry • Improve staff morale • Re-establish budgetary control • Re-commence recruitment • Strategic plan for future

14. MINIMUM COMPONENTS OF CLINICAL GOVERNANCE • Credentialling, Privileging and Performance Review • Critical Incident Reporting and Investigation – backup systems • Complication monitoring (e.g. Y codes) • Recommendations from Audits/Case Reviews • Hospital Wide Clinical Indicators • Specialty Specific Clinical Indicators • Risk Analysis of Environmental and Support Systems • Customer Feedback • Commitment to Staff Development and Training • Control of New Services & Equipment

15. MANAGING THE ENVIRONMENT • Internal Communications – - open – door policy for executive - executive outreach to all areas - HOD & staff forums - monthly newsletter & frequent e-news - update of intra & internet sites • Management of External Environment – - media policy & regular good news + media briefings - regular meetings with politicians - utilise hospital volunteers & other support groups

16. MANAGING THE ENVIRONMENT (CONTINUED) • Manage the Inquiry - anticipate the inquiry recommendations - give regular media briefing on reform process to mitigate Inquiry Report - debrief & support staff giving evidence to Inquiry • Improve Staff morale - staff consulted at all stages - staff recognition awards - encourage staff education & development - support staff social events - publicly praise staff & services at all opportunities

17. FURTHER ACTIONS TO REBUILD • Re-establish budgetary control - Establish budget planning cycle - Review workforce establishment - Negotiate budget deliverables - Negotiate funds required to rebuild –staff and capital • Recommence recruitment - aggressive recruiting campaign - utilise key clinical leaders networks - sell challenge of rebuilding

18. FURTHER ACTIONS TO REBUILD (CONTINUED) • Strategic plan for future - Vision for next 5 years – owned by staff - Get political support to rebuild services - Aim high with vision so positive gain from disaster

19. OUTCOMES FOR KEMH AT END OF 2 YEARS • Comprehensive governance system • Full staffing including 11 more full time specialist staff (previous only 3) including 5 professorial positions • Balanced budget • Both KEMH & PMH developed expanded State-wide role in line with new 5 year vision • $30 million redevelopment for KEMH & $35 million redevelopment at PMH proposed • Excellent staff morale • Returning community trust

20. OUTCOMES FOR BUNDABERG AFTER 9 MONTHS • Clinical governance system operating • Improved staff morale • Positive media for last 4 months • Recruitment of staff proceeding to new establishment – should be complete by Jan 2007 • Inquiry recommendations nearly implemented • Patel affair nearing settlement of claims • Bid to politicians for major capital redevelopment Will take at least 2 years to recover!

21. SPECIAL PROBLEMS FOR RURAL DISTRICTS • Small number of specialists – credential, appraisals, audit • Shortage of nurses and allied health • Support for education/ up-skilling, relief • Competition between hospitals for recruitment • Linkage to tertiary/ larger centres for services and support – visiting, Telehealth, backfill for updates • Service continuity risks • Patient access to care

22. LESSONS FROM DISASTERS • Be informed of Critical Events - have back up systems in place • Be available & communicate with staff – outreach regularly • Ensure credentialling, privileging & performance review is sufficiently broad based to be independent – both senior & junior staff • Ensure effective system for managing poorly performing clinician • Ensure delineation of surgical privileges in line with role of hospital • Ensure effective system to manage introduction new services/ technology • Ensure IT system responsive to clinical governance needs • Ensure effective customer services • Ensure effective governance reporting system