Kupu Taurangi Hauora o Aotearoa

1. Kupu Taurangi Hauora o Aotearoa

2. Quality and Safety are at the • Heart of Clinical Practice • “To Err is Human” – Institute of Medicine Report -- 1999 • Peter Davis NZ-- 2002 12.9% medical error • Australia -- 16.6% • Britain – 10.8% • “First Do No Harm”

3. Key Questions • How can you tell you are delivering a quality service, and a safe service? • What information do you use? • How does a “system” answer the same questions? • How do you and/or the system change if you need to?

4. The Commission • Formally established under the New Zealand Public Health and Disability Act 2000 in November 2010 • Crown Agency under the Crown Entities Act 2004 • Has picked up many of the programmes of the former Quality Improvement Committee

5. The Commission Supporting the health and disability sector to deliver safe and quality health care to all New Zealanders

6. The Commission Works with clinicians, health providers and consumers to: • improve the quality and safety of services • increase consumer engagement and participation

7. It’s about… • ‘Shining a light’ on important quality and safety issues through public reporting • ‘Intelligent Commentator’ through analysis and knowledge • ‘Lending a helping hand’ through making expert advice, guidance and tools available “Doing the right thing, and doing it right, first time”

8. Our Role

9. The New Zealand Triple Aim Sector quality and safety outcomes

10. Key elements of quality

11. Our focus Reducing harm from: in-patient falls hospital-acquired infections medication surgery Consumer engagement Sector capability & clinical leadership Information, analysis and evaluation

12. Our programmes Our “building blocks” • Reportable Events • Consumer Engagement • Mortality Review Committees • Leadership and Capability building • Health Quality Evaluation • Medication Safety • Infection Prevention and Control • Surgical Safety • Falls • (Trigger Tools)

13. Medication Safety • Medication safety is about making sure the right patient gets the right medicine in the right dose at the right time and by the right route • Our focus is on: • prescribing and administration • safety of transitions of care • electronic medicines managementin hospitals • high-risk medicines and situations • measurement and evaluation

14. Infection Prevention and Control • Up to 10 percent of patients admitted to hospitals in the developed world acquire one or more infections • Our focus is on: • health care workers using 5 moments of hand hygiene (partnership with Auckland DHB) • reducing patient risk of infection by greater use of central line insertion and maintenance bundles (partnership with Counties Manukau DHB) • reducing the harm and cost relatedto surgical site infection

15. Falls Prevention • Falls prevention is a new programme which aims to reduce harm associated with preventable falls • The initial focus will be on in-patients and aged residential care • Community/Primary /Hospital • integration

16. Surgical Safety Checklist The Commission is supporting the adoption of the Surgical Safety Checklist. The checklist is a tool to improve the safety of operations and reduce unnecessary death and complications by: • reinforcing accepted safety practices • fostering better communications and teamwork Our goal is - ‘Every theatre, every case.’

17. Trigger Tools • The Commission is developing a work programme to help implement the Global Trigger Tools programme in New Zealand • Trigger Tools is a quality improvement initiative being used internationally to reduce patient harm • Analyses random samples of patient records looking for ‘triggers’ which may indicate harm has occurred • Information gained is used to improve the quality and safety of services

18. We know what works Evidence tells us that with the right interventions: • patient falls that result in fractures can be reduced by up to 30 percent • CLAB rates can be reduced to fewer than one per 1000 bed days • surgical complications can be reduced by about a third • potentially adverse drug events can be reduced by a quarter HARM

19. Development of Quality & Safety Markers • QSMs enable us to identify how many effective interventions are being used in our hospitals, and the expected reduction in harm and improvement in health they will bring • Focused initially on reducing harm form falls, hospital acquired infection, medication error and surgery • Measures for expected harm reduction will be developed in consultation with the sector • Baselines developed by December 2012, shared with sector • Baselines published June 2013 • Public reporting on progress against measures June 2014, and six monthly thereafter

20. Reportable Events • The Commission reports annually on the serious and sentinel events that occur in our hospitals • 377 events in 2010/11, 86 patients died • Falls were 52 % of SSEs reportedin 2010/11 • No other significant changes in thepattern of SSE reporting • Adverse events reporting policy agreed • Moving to reporting in other settings – community, primary and private • Mental health adverse events, including deaths by suicide after discharge, now reported separately

21. Consumer Engagement

22. Consumer Engagement • The Commission supports consumer/family participation and decision making about health and disability services at every level • We have: • supported a national collaboration of health consumer organisations • developed a directory of consumer organisations • a focus on health literacy and medication safety • sponsored international experts onconsumer engagement to come toNew Zealand • an eight month learning programme

23. Mortality Review Committees Review particular deaths, or the deaths of particular people to learn how to best prevent these deaths • Family Violence Death Review CommitteeChair: Associate Professor Julia Tolmie • Perioperative Mortality Review Committee Chair: Dr Leona Wilson • Child and Youth Mortality Review Committee Chair: Dr Nick Baker • Perinatal and Maternal Mortality Review CommitteeChair: Professor Cynthia Farquhar

24. Health Quality Evaluation • National set of quality and safety markers, which include the four focus areas (falls, hospital-acquired infections, surgery, medication) • Atlas of Healthcare Variation • Quality accounts • Quality and safetyindicators

25. Driving quality improvement • Building capability • Supporting clinical leadership • Building on the success of existing initiatives • Sharing success stories

26. Engagement across the sector

27. Relevance for older peoples’ health services • The Triple Aim • Quality improvement culture • Reporting adverse events • Medication safety – aged care medication chart; polypharmacy review; “medicine alerts” • Infection prevention and control • Reducing harm from Falls • Consumer/family engagement • Clinical leadership

28. Our Board Professor Alan Merry (Chair), Head of Department for Anaesthesiology at the University of Auckland’s School of Medicine Dr Peter Foley, Chief Medical Officer - Primary Care, Hawkes Bay DHB Mrs Shelley Frost, Deputy Chair and Executive Director (Nursing) of General Practice New Zealand

29. Our Board Dr David Galler, intensive care specialist at Middlemore Hospital Dr Peter Jansen, Senior Medical Advisor to ACC Mr Geraint Martin, Chief Executive Officer of Counties Manukau DHB. Mrs Anthea Penny, Director of R H Penny Ltd, Australasia

30. What we don’t do • Handle individual consumer cases or complaints • Enforce regulations or legislation • Quality assurance or compliance auditinge.g. for certification • Credentialing or registration of individual clinicians • Fund health and disability services

31. Our website: www.hqsc.govt.nz • Register for our newsletter and fortnightly email updates • Contact us: info@hqsc.govt.nz

32. Kupu Taurangi Hauora o Aotearoa