Founding Chapter Clinical Governance Roundtable

1. Founding ChapterClinical Governance Roundtable 6-8 August 2002 Brisbane

2. Contents (1) • Overview of The Health Roundtable • Clinical Governance Background • Thought-Starter Presentations 6/8/02 • Shared meanings for ‘Safety and Quality’ • Sentinel/adverse management • Initial response to an incident • Assessing possible poor clinician performance

3. Contents (2) • Managing the impaired clinician • “No blame” or “just” culture? • Focus on error prevention • Clinician Workforce Safety Issues • Douglas Review Ideas Check-list • Redesign patient care deliveryaround actual patient needs

4. Contents (3) • Governance in context • Data-driven Error Reduction Strategy • Practice Improvement Team-Based Learning • NSW Clinicians’ Toolkit • Morbidity & Mortality Meetings • Compare and learn internationally • Creating the culture for Clinical Governance

5. Contents (4) • Comparative Self-Evaluation using ACHS Accreditation • ACHSMandatory Criteria • Cost Benefit Theory • Hospital Action Plans • NHS Clinical Governance changes • Relevant Web Links • Mandated Sentinel Event Reports

6. Overview • Health Roundtable Background • Ground Rules • Background on Clinical Governance • Related Information • Key Issues

7. The First Health Roundtable Convened in November 1995 by Bill Kricker and John Youngman • Seven Hospital CEOs and their “Innovators” • Operational Improvement Focus • Data Sharing to Find Innovative Practices • Sponsored by CSC Australia

8. Our Focus - Removing “Rocks” • Conditions are tightening, reducing margin for error • Flaws in operations are exposed, like rocks in a stream bed • Rather than navigate around them, find ways to remove the rocks • Focus on simplifying operational practices

9. HRT Expertise Clearinghouse Why a Roundtable?

10. Health Roundtable ... The Health Roundtable Limited Non-profit membership organisation • Grown to Two Chapters Founders All Stars • South Auckland • Canterbury Health • Royal Perth • Royal Adelaide • Alfred Hospital • Royal Melbourne • Royal North Shore • Liverpool • Royal Brisbane • Princess Alexandra • John Hunter • Capital Coast - Wellington • Westmead • St George • Flinders • Queen Elizabeth • Sir Charles Gairdner • Fremantle • Royal Hobart • Austin & Repat • Geelong • Townsville

11. Corporate Partners • Opportunity to hear key issues first hand • Provide financial support for Roundtable activities • Two Corporate Partners in 2002: • The Cerner Corporation • Schering-Plough Pty Limited

12. 1.Knowledge 1.Knowledge 3. Decision 3. Decision 2. Persuasion 4. Implementation 5. Confirmation Fostering Innovation The Health Roundtable Process

13. Ground Rules • “Honour Code” • Focus on operational issues • Expectations: learn and teach • Active participation by CEOs and Staff Contents

14. Clinical Governance Background • Simmering Issue for several years • Focus of All Stars meeting in 2001 and 2002 • Organisational structure • Death Audits • Sentinel Events Monitoring • Added to KPI processes this year • Still a Major Issue for most hospitals

15. Related Information • Falls Roundtable Results • 9 hospitals over 12 months • Many improvement initiatives tried • Limited success at actual falls reduction • Key: increased patient surveillance • Problem: how to organise and fund

16. Related Information • 11 New Casemix Key Performance Indicators • Procedures not performed • Pressure ulcers • Cardiac Arrests • Inpatient Falls • Surgical events • Medical events • Mortality levels • Inpatient poisoning • Drug Events • Misadventures during care • Medical device problems

17. Key Issues for 2002 • How to structure for clinician support? • What Key Performance Indicators to use? • How to link credentialing and outcomes? • How to review sentinel events? • What to centralise or decentralise? • How to report to the public and the media?

18. Current Status • Most use similar clinical governance terms: • Assure staff are qualified • Assure appropriate equipment • Assure safe clinical practices • Monitor clinical performance • Take corrective action • Build CQI culture

19. Current Status • Eight have credentialled all medical staff • Six have privileges documented • Three have CQI in all clinical units • Few monitor patient feedback by clinician • Almost all have more developed processes for nursing and allied health than doctors

20. Current Status • All are building supportive culture • Nine have “no blame” practices • Eight assure new work practices are safe • Four achieve 75+% informed consent • Two identify most adverse incidents Contents

21. Thought-Starter Presentations 6/8/02(See www.healthroundtable.org) • Princess Alexandra – Patient Safety Team to minimise preventable harm • John Hunter – Sternal Infection Root Cause Analysis • Liverpool – Encouraging reporting of events in anaesthesia • Royal Adelaide – Sentinel Event Panel • Alfred – Clinical Review Committee • Safety & Quality Council - King Edward Review • Royal Melbourne - Internal Review Contents

22. Some ‘shared meanings’ in Safety and Quality (1)Source: Australian Safety & Quality Council • Accountable “being held responsible” • Accreditation “being granted recognition for meeting designated standards” • Adverse event “incident in which harm resulted to a person receiving health care” • Credentialling “process of assessing and conferring approval on a person's suitability to provide a defined type of health care”

23. Some ‘shared meanings’ in Safety and Quality (2)Source: Australian Safety & Quality Council • Incident “event or circumstance which could have, or did lead to unintended and/or unnecessary harm to a person, and/or a complaint, loss or damage” • Sentinel event “incident with actual or potential serious harm or death” • System failure “fault, breakdown or dysfunction within an organisation’s operational methods, processes or infrastructure” Contents

24. Sentinel/adverse event response • Sentinel events should be investigated individually & early (don’t wait for more!) • Specialty reviews where local issues for local action • Hospital-wide issues referred to executive level Committee for wider action • Notify the CEO electronically when any major incident occurs • Trend data for less serious incidents/events

25. Investigating sentinel/adverse events • Who should investigate/review major sentinel events or similar problems? • Multi-disciplinary • Core team with expertise • Others depending on situation • External support / oversight

26. Sentinel/adverse event consultation • Whom to consult about the problem • Family • Witnesses • Staff directly involved and supervisors • Either one-on-one or group in a problem-solving approach

27. Sentinel event review options Two types of review may be needed in parallel Safety Improvement Enforcement Of Rules Coordination Required! No blame culture Root cause analysis Systems approach Feedback loop Improvement actions “Just” Culture Refer to authorities Individual focus Legal requirements Remedy / Punish

28. Consumer involvement when errors occur What consumers want when problem occurs: • Open disclosure • Apology • Remedial action taken to prevent recurrence • Issue: How to involve consumers (the family) in the incident review?

29. Corrective / Preventive Actionsfor error reduction • Focus on systems improvement rather than personal blame • Disclosure to family • Disclose to other departments, hospitals • Monitor implementation of the change • Re-audit the process to ensure change works

30. Using trend data to detect care variation and target risk areas • Standardise for casemix, risk & severity • obtain statistical advice • Compare practitioner performance vs peers • monitor overall continuum for each patient’s care • monitor each clinician’s patient outcomes (e.g. Palm Pilot/Bolsin model) • Mortality alone not enough – too blunt, too late • Built data capture, analysis into the daily processes Contents

31. Initial response to an incident (1) • Notification by electronic incident form with tracking • Clinical Review Team (Executive appointed) • Culture = improving safety is part of everyone’s job

32. Initial response to an incident (2) • Notification by electronic incident form with tracking • Family advised early – involve consumers in analysis • Want open disclosure, apology and action/policy to prevent recurrence • Track/link patient’s progress beyond incident

33. Initial response to an incident (3) • Clinical Review Team (Executive appointed) • Multi-disciplinary structure – med, nursing, allied, pt safety/risk mgt + learner • Core members – patient safety, divisional director plus specialists • Root cause analysis one piece – does not guarantee action • Report to CEO/snr mgt team to achieve ‘clout’

34. Initial response to an incident (4) • Culture of improving safety should be part of everyone’s job • Break-through re-design needed, incremental change too slow • Emphasis on ‘system’ improvement with protocol-driven care • Follow-up of action taken to ensure improvement

35. Increase transparency for incident ‘review  action  gains held’ (1) • Early/open disclosure and involvement in review of all involved • external expert (e.g. College), peers, admin, family and Consumer Advisory Council • Decentralise initiation and review • structure & document M&M meetings, recommendations to feed into the whole system and interfacing services • central monitoring of implementation & gains held

36. Increase transparency for incident ‘review  action  gains held’ (2) • Multi-disciplinary involvement in review • documented analysis and ‘effective action’ plans implemented, tracked at Executive/Board levels • Extend the lessons from each error organisation-wide Contents

37. Assessing possible poor clinician performance (1) • Review individual clinician outcomes data compared to peers: • unit as a whole against ‘better/best practice’ • Look for unexplained high variation • Adjust outcome data for casemix (risk) and severity (APR-DRG 1-4 severity)

38. Assessing possible poor clinician performance (2) • Participate in ongoing state/national peer reviewed outcomes databases to detect trends e.g. • Victorian vascular surgery database • Routine/regular review by audit committee, linked to ‘natural justice’ processes (data problems as the cause need to be excluded) • Personal Professional Monitoring

39. Personal Professional Monitoring(individual Palm Pilot data) • Data self-monitoring personal IT system designed for Registrars • found useful by Consultants & House Officers • Barwon Health [Steve Bolson] lead site for this development • clinicians own and measure their own performance data • nationally collated and reviewed by peers at College level, not State or Hospital • Provides tools to make performance monitoring easier and more acceptable Contents

40. Managing the impaired clinician Major incident review team needs to advise on the key cause & response Individual? System? • Strengthen prevention • & surveillance systems: • Incident monitoring • Mortality & Morbidity • Clinical indicators • Clinical risk • management framework • Medical Services • Human resources • Industrial relations • Professional support (counselling, College, etc) • Credentials & • Clinical Privileges • use pre-determined framework & roles/personnel • informal temporary step-down ideal • External liaison • Media / Govt • Patient / Family Remedial Support Contents

41. “No blame” or “just” culture? • Start incident investigations as ‘no blame’, with criteria to switch to ‘just’ format if evidence of negligence found • Standardised review/investigation protocol and method training for personnel involved • External constraints to ‘no blame’ culture: • Mandatory notification • No fault insurance • Statutory protection • Governance ‘of’ [Board’s responsibility for accountability] vs. ‘by’ [those responsible for care get together to try and solve it] Contents

42. Focus on error prevention for real gains in safety • Airlines, mining, OH&S lead the way ! • Need agreed clear principles and evidence-based practice procedures to reduce chance of error • Current culture of autonomous practice by health professionals is a major barrier • IT solutions demonstrate the major gains • Less error requires less tolerance or error by providers and consumers Contents

43. Clinician Workforce Safety Issues (1)Maintain culture/systems of ‘everybody has someone to go to’ with errors/problems • When in doubt, SHOUT! • Reverse medical culture to not complain/seek help • Define escalation check-list with clear criteria for calling help e.g. Horsham registrar call ED criteria • Define clear on-call responsibility • Promote use of aids and assistance, not memory • Detailed/regular performance feedback • Executive to specialists, specialists to resident staff • counselling support needed for behavioural change (as for 360º feedback)

44. Clinician Workforce Safety Issues (2) quality/safety =  efficiency & cost • ‘Hospitalist’/geographic full-time specialists to increase commitment & reduce reliance on junior medical staff • One benefit of private hospital co-location • Enforce safe working hours policy for all levels of medical staff • Re-design care around the needs of the patient, not clinicians = 24/7/365 (not 8/5) • Multiple duplication of history/examination delays care and increases safety and quality risks! • IT solutions available to reduce documentation burden/delays Contents

45. Douglas Review Ideas Check-list (1) • Review performance of statutory committees • are they actually finding and fixing risk assessed priority problems? • Is mortality/morbidity review process working? • Have you commissioned an external review of policies and procedures to verify that things are actually working as planned? • Do we need senior staff to be present at night, or available on call? What technology could assist with the process? • What is the out of hours coverage by medical staff? Lack of expertise and supervision? Culture of sink or swim?

46. Douglas Review Ideas Check-list (2) • Workforce staffing 1960’s model for 21st century issues? • How to assess competency of junior staff on key care processes? • Dealing with external standards imposed by ACHS, colleges, or government? • Tracking problems and responses by management to “close the loop”? • Managers allocating time to high risk clinical patient care review? • What is the Board/executive told about problems and solutions? KEY NEXT STEP: Do a self-assessment against the Bristol and/or King Edward recommendations to see where your hospital stands. Contents

47. Redesign patient care deliveryaround actual patient needs • Focus on defined patient needs rather than departments or specialities • Streamline and optimise patient flow through the system, for the patient e.g. • fractured Neck of Femur flow from ED direct to OT • Substitute alternative staff/skills/services to match defined care needs • Reduce repetitive history taking by all staff • redesign better access to diagnosis and treatment (IT) Contents

48. Governance in context • View ‘Clinical’ issues as part of overall Governance process • Are we providing safe, quality care? • How do we know? • Need more ‘balanced’ safety, quality and cost indicators? • Alerts able to avoid surprises in media? • Risks assessed and managed effectively? • Adequate staff/processes to reduce risks?

49. Simplify ‘Safety’ terminology ? • Is “Clinical Governance” a necessary term? - or just “Governance” of/by all • Is “Patient Safety” a necessary term? Or just “Safety” for all • Is “Clinical Risk Management” a necessary term? Or just overall “Risk Management” Perhaps terms are evolutionary for initial advocacy – better ‘build-in’ once profile and meaning established with clinicians and managers.

50. Share Risk Management Response‘Board  Providers of patient care’ • Require management to develop data-driven options for Board review • avoid Board micro-management of care • Safety/quality may not cost more in long term • do cost-benefits analysis of risks/options • Often, biggest barriers are culture, industrial relations, rather than cost “We have met the enemy, and it is us!” Contents