Why is ACS&QHC Interested?

1. Lessons from the Inquiry into the King Edward Memorial Hospital Obstetrics and Gynaecological Services Presentation to Womens Hospitals Australasia/ Childrens Hospitals Australasia National Conference, Perth, 10 April 2001 by Dr Michael Walsh, Deputy Chair, Australian Council for Safety and Quality in Health Care

2. Why is ACS&QHC Interested? • Make the findings of the Inquiry more accessible and relevant • Identify lessons and opportunities for system change • Identify lessons and opportunities for operational management and governance change • Work cooperatively with stakeholders (KEMH, HDWA, WHA/CHA)

3. Overview of Discussion • Review of Inquiry and Findings • Lessons for Health Care Institutions: • operational/clinical management • governance • Lessons for System and Policy-makers

4. King Edward Profile • WA’s only tertiary referral services for obstetrics and gynaecology • 250 inpatient beds, neonatal intensive care, outpatients and specialist emergency services • 5,000 births per year • 5,000 gynaecology operations • 8,000-10,000 emergency presentations • High and increasing case complexity

5. Lead-up to Inquiry Significant change and upheaval including: • merger with children’s hospital • two new chief executives; devolved management • focus of MHSB taskforce to review WA O&G • steering group reviewed recommendations • independent review by retired clinician • Child and Glover review • strong public debate about future of KEMH

6. Inquiry’s Brief • Established under Hospitals and Health Services Act • Examine management and clinical practices, policies and processes from 1990 to 2000 • Focus to “identify and assess the deficiencies” (1) • Recommend changes to improve short-comings 1.Executive Summary, Inquiry into KEMH 1990 to 2000, Final Report, Vol.1, November 2001

7. Method • Extended over 18 Months • Accessed information from 1600 patient files • Analyzed 605 patient files • Analyzed ninety-six medico-legal cases • Compared KEMH clinical performance data with 13 similar Australian services (Consortium) • Reviewed 293 written submissions • Interviewed 70 former KEMH patients • Read 106 transcripts, reports & other documents • Resource intensive (expensive)

8. General Observations regarding Inquiry Report • Very long and difficult to access • Language of system failure; reality of great detail and “naming names”. • Was the Inquiry welcomed? • Readership? • Minister/Government? • Institutional Governance? • Management/Staff? • Patients/General Public • All of the above?

9. Limitations • Inquiry Approach • negative bias; adversarial • lengthy; expensive • Prone to political influence; • Focus on high-risk cases; • Non-representative sampling; • Limited inter-hospital comparison;

10. Strengths • Level of detail of review • Case studies for learning/teaching purposes • Focus on clinical practice issues not usually talked about: • standards of care • responsibility and accountability • supervision of juniors • credentialling and training • Discussion of management responsibilities for safe care

11. Findings - Strengths • Many examples of exemplary care & service • Concerted effort by some to address or improve long-standing problems

12. Findings - Management Management failed to: • make & act on important decisions • create an open, transparent, positive culture • monitor & improve safety & quality • clarify accountability, responsibility & reporting • ensure staff were properly trained/supervised • address serious clinical issues adversely affecting care & clinical outcomes

13. Findings - Senior Doctors • Insufficient involvement in complex cases • Inadequate, delayed or absent decisions • Inadequate credentialing, appointment, re-appointment, admitting privileges processes • Inadequate performance management • Inadequate supervision/training of juniors • Failed to provide timely, detailed analysis of staffing needs

14. Findings - Junior Doctors • Left to do much of the complex work • Unreasonably burdened with difficult cases • Inadequately supervised/supported • Requests for help often delayed or ignored • Blamed for errors - “sink or swim” • Inadequate orientation & training • Supported more by midwives than senior doctors

15. Findings - Clinical Practice Ineffective or absent: • care planning, coordination, documentation • policies & practices based on best evidence Poor management of: • complex & emergency cases • women needing intensive care services • incidents & adverse events Poor clinical & emotional outcomes for women & families

16. Findings: Clinical Review & Reporting Inconsistencies in: • review and report of deaths to the Coroner • report, review and response to incidents & adverse events • management of complaints and medico-legal cases • review & compare clinical performance & respond to performance issues

17. Findings - Internal Policies and Processes Absent or inadequate: • quality improvement program • incident/adverse event monitoring & follow-up • complaints & medico-legal case management • committee functioning & review • policy development, deployment, review • recruitment, employment, performance management, training

18. Findings - Women & Families • Often excluded from decisions about care • Concerns ignored or overlooked • Treated poorly as complainants • Given untimely and inadequate information, particularly when things went wrong • Rarely involved in policy decisions

19. Comparison with Bristol • Heart surgery on babies in Britain’s Bristol Infirmary from 1988 to 1994 • Deaths following arterial switch operation • Excessive time take to do procedure • Concerns raised repeatedly by an anaesthetist • Senior doctors and chief executive eventually faced prosecution

20. Common Themes In both cases, management’s failed to: • respond to important issues raised repeatedly • ensure clinicians were properly trained • build a culture of transparency/open disclosure • establish effective quality systems • give patients & families adequate information about risks, care & problems with care • effectively manage complaints/medico-legal cases

21. Lessons for Institutional Management and Governance 1. Leadership & Culture 2. Accountability & Responsibility 3. Safety & Quality Systems 4. Staff Support & Development 5. Concern for Consumer & Families

22. System Issues Institutional Governance • Role of Board, Management in Patient Safety • Importance of Benchmarking and Comparative Data • Importance of Incident Monitoring, Reporting, Management and Review • Importance of Mortality Review • Importance of Periodic External Review of Management Policies, Procedures and Practices

23. System Issues System Governance • Role of Regulatory/Statutory Authorities • Mortality Committees; • Coroner • Role and Function of External Accreditation • Standards of practice (incl credentialling) • Role and Structure of “Special Inquiries” • Importance of Comparative Data • voluntary versus mandatory • clinical privilege (Immunity) • public disclosure

24. Conclusions • Inquiry is a landmark in the evolution of health care safety and quality policy and practice in Australian hospitals; • ACS&QHC Summary and Implications document should be required reading for all hospital managers and Boards • We should learn from the Inquiry findings and limitations to develop better ways of monitoring and reporting safe patient care environments.