Patient Safety in Public Hospitals
1 EXECUTIVE SUMMARY
1.1 Introduction
The risk that patients are harmed while receiving healthcare can
never be mitigated entirely. Nevertheless, estimates suggest
approximately 50 per cent of care-related injuries are avoidable,
and the challenge for health services is to ensure their patient
safety systems minimise the risk of harm.
Health services take a ‘systems’ approach to preventing
incidents, acknowledging that while human error is unavoidable, the
conditions that people work under can be controlled. Rather than
blaming individuals, the ‘systems’ approach attempts to identify
the underlying causes of incidents, and establish mechanisms to
prevent them from recurring.
Clinical incidents are incidents that occur in a health setting
that could have resulted, or did result, in the harm of a patient.
In Victoria, the Department of Human Services (DHS) categorises
clinical incidents according to the degree of harm, or potential
harm, they cause. They range from near misses (incidents avoided
through hospital strategies) to serious incidents.
Clinical incidents can have serious health and quality of life
consequences for patients. At worst, they can result in death, and
they can also have significant financial implications for health
services, with costs estimated at around $511 million annually in
Victoria.
The precise number of clinical incidents that occur in Victorian
hospitals is difficult to estimate. Not all clinical incidents are
recorded, and there are no data collection systems to aggregate
their number and type. Several studies estimate that clinical
incidents are associated with around 10 per cent of hospital
admissions. In 2006-07, Victoria’s public health services admitted
1.35 million patients. This means that around 135 000 patients
may have experienced a clinical incident—a proportion of which may
have been serious. A concerted and systemic effort is warranted to
reduce this number.
1.2 Findings
1.2.1 Patient safety governance
The audit looked at five health services. All had developed
organisation-wide risk management frameworks, which included
clinical risk. These frameworks outlined a consistent approach to
treating and reporting of clinical risk. However, at the statewide
level, there has until very recently been no overall quality and
safety framework to guide and prioritise patient safety
activity.
The relevant agencies had clearly documented descriptions of
their own responsibilities, but there were instances where these
responsibilities overlapped. This created uncertainty within the
system. Overlap and duplication was most evident in the roles and
responsibilities of the Victorian Quality Council (VQC) and the
Statewide Quality Branch (SQB). These agencies provide the majority
of expert guidance and advice on quality and safety issues, and the
overlap and duplication between these agencies has obscured
leadership in the patient safety system. With unclear leadership,
driving change and improvement will be harder.
Coordination arrangements for patient safety are not clear. DHS
advised that it was taking steps to improve coordination through
the development of SQB’s new statewide role and
responsibilities.
An effective patient safety regime requires collaboration and
the sharing of knowledge among agencies. Numerous collaborative
relationships exist in the patient safety arena. These provide a
useful foundation for agencies to increase the sharing of ideas and
contribute to sector-wide patient safety planning.
1.2.2 Patient safety performance
In Victoria there is no incident monitoring system that collates
patient safety data across the state. Victoria is the only
jurisdiction in Australia that does not have a statewide system to
monitor the patient safety system’s performance.
While some statewide data are collected, such as sentinel
events, infection rates and pressure ulcers—these represent only a
proportion of the available patient safety data. Consequently, DHS
is unable to measure the safety performance of the system as a
whole. The Minister for Finance’s response to VAGO’s 2005 audit
recommendations informed Parliament that DHS would address many of
the issues raised through its clinical governance policy.
DHS had engaged a contractor to consult with stakeholders on the
clinical governance policy, at the time of the audit fieldwork. A
draft clinical governance policy has since been developed that
should address many of the issues identified in 2005.
The reviews of SQB and VQC, along with the action taken to date
to develop a new clinical governance framework and a statewide
incident reporting system, are important initial steps to improve
patient safety. More significant change and innovation is required
to bring about the improvements necessary to reduce Victoria’s high
number of patients who experience harm while in the hospital
setting.
In the meantime, accountability for patient safety in Victoria
will continue to be weak, effectively masking an unacceptably high
level of incidents behind data gaps and inadequate reporting. The
way forward in patient safety requires a step-change in how
agencies work together to design and implement safety systems and
manage the health system as a whole.
1.3 Recommendations
Statewide governance
DHS should implement, as a priority, the recommendations from
its 2007 review of the Quality and Safety Branch
(Recommendation 3.1).
RESPONSE provided by
Secretary, Department of Human Services
The department is implementing the
recommendations from its 2007 review.
Improvements in patient safety governance
DHS should implement, as a priority, the outstanding
recommendations from the previous performance audit, as outlined in
the Minister for Finance’s report to Parliament. In particular, DHS
should advise health services of appropriate clinical incident
definitions (Recommendation 3.2).
RESPONSE provided by
Secretary, Department of Human Services
The recommendations made in 2005 resulted in two large scale
projects being developed, these being the Review of clinical
governance in Victorian public health services, with the objective
to develop a statewide framework to ensure clinical governance is
supported, and the Incident information system project, to
establish a statewide reporting capacity for all incident
data.
The clinical governance framework
project has delivered a draft framework and way forward for
Victoria which is currently being reviewed by quality and safety
groups and the department.
Both these projects will address the recommendations made in
2005 and are being progressed as a matter of priority.
Statewide performance monitoring
DHS should implement the incident information system or a
similar system with statewide reporting and analysis capability as
a priority (Recommendation 4.1).
RESPONSE provided by
Secretary, Department of Human Services
The Incident Information System
(IIS) development commenced in early 2006 and is a significant
project.
- To date the following
outcomes have been achieved through the IIS project.
- A clear set of definitions relating to
clinical incident management.
- Establishment of a standardised
incident severity rating (ISR) methodology.
- Development of a standardised
incident classification model based on World Health Organisation’s
International Classification for Patient Safety
(WHO IC4PS).
- Development of an incident
data set that formally defines the clinical incident information to
be collected and the associated data collection
methodology.
The development of a comprehensive
taxonomy and data dictionary is reaching completion. It is now a
matter of software development by others; implementation of data
streams for hospitals to the department, VMIA, the Health Services
Commissioner and Worksafe; implementing the necessary data storage;
and developing the benchmarks and feedback reports to all
stakeholders. The scope of the project has been altered over time
in response to requests from hospitals to ensure the approach is
reflective of a whole suite of incident management, not just
clinical incidents. An appropriate business case will be finished
in 2008. Training within hospitals will be a key to the success of
the project.
Internal accountability
DHS should establish a performance measurement framework to
enhance internal accountability for patient safety
(Recommendation 4.2).
RESPONSE by Secretary,
Department of Human Services
The department is developing a
program measures framework to underpin measures associated with the
Statement of Priorities (SoP). This framework will monitor
performance against the measures while identifying measures for
inclusion in subsequent SoP iterations.
A new set of performance indicators associated with
Australian Health Care Agreements include a number (to be
finalised) of quality indicators that are currently in development.
The department is contributing to the development of this list of
indicators.
The department funds and
participates in a number of external registry projects aimed at
measuring quality of care. These focus on high risk/high cost
clinical areas such as cardiac surgery and intensive care. The data
from each registry is subject to review with feedback mechanisms in
place. Many of these will be further developed through the clinical
governance framework.
RESPONSE provided by
Secretary, Department of Human Services
Extracts from the Secretary’s response relevant to the
recommendations have been included in the text above. The full text
of the Secretary’s response has been reproduced at Appendix D, page
43.
RESPONSE provided by the
Chief Executive Officer of the Victorian Managed Insurance
Authority (VMIA)
A response provided by the Chief Executive Office of the VMIA,
which does not refer specifically to the recommendations is
included at Appendix E, page 51.
RESPONSE provided by Acting
Secretary, Department of Justice
The Department of Justice welcomes
the report and, through the State Coroner’s Office, will continue
to collaborate with the Department of Human Services to improve
patient safety.