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1 Please note that the following document was created by the former Australian Council for Safety and Quality in Health Care. The former Council ceased its activities on 31 December 2005 and the Australian Commission for Safety and Quality in Health Care assumed responsibility for many of the former Council s documents and initiatives. Therefore contact details for the former Council listed within the attached document are no longer valid. The Australian Commission on Safety and Quality in Health Care can be contacted through its website at or by Note that the following document is copyright, details of which are provided on the next page.

2 The Australian Commission for Safety and Quality in Health Care was established in January It does not print, nor make available printed copies of, former Council publications. It does, however, encourage not for profit reproduction of former Council documents available on its website. Apart from not for profit reproduction, and any other use as permitted under the Copyright Act 1968, no part of former Council documents may be reproduced by any process without prior written permission from the Commonwealth available from the Department of Communications, Information Technology and the Arts. Requests and enquiries concerning reproduction and rights should be addressed to the Commonwealth Copyright Administration, Intellectual Copyright Branch, Department of Communications, Information Technology and the Arts, GPO Box 2154, Canberra ACT 2601 or posted at

3 SAFETY IN PRACTICE Making Health Care Safer Second Report to the Australian Health Ministers Conference 1 August 2001

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5 STATEMENT FROM THE CHAIR Most Australians enjoy access to a comprehensive range of health care services supported by modern technology and a well trained and motivated workforce. While we believe that Australia s health care system is among the best and safest in the world, it doesn t mean that our system is free from risk. Modern health systems are complex, offering a wide range of services, across many disciplines around the clock. Like any high risk industry, it is, therefore, hardly surprising that errors and system failures occur within health care. As information becomes more widely available and community expectations of the health care system grow, governments, health professionals and consumers are becoming increasingly concerned about the incidence of adverse events. With approximately 10% of hospital admissions in Australia and other developed countries being associated with an adverse event and the cost of unsafe health care running at around $1 billion a year, improving safety has become a matter of national importance. It is, however, not an easy task to move from a 90% good result to a 95% or 98% result. Every patient matters and we can, and should, be doing better in the 21 st century to manage risks and redesign systems in health care. Of particular importance is the need for health care management at all levels to allow health clinicians and nurses at the front line to influence management decisions effectively. Management has a necessary focus on improving efficiency, but this alone will not improve safety and quality. Management must also fund and encourage redesign of systems, monitor activity reports, feed their results back and reward safety improvements. We also need to change the culture in health care. Safety must become core business for everyone an integral part of health care delivery every day. As part of this change, all who work in or have responsibility for the health care system need to be willing to work with their peers to examine more openly and objectively their performances and patient outcomes. In the community, we need to move beyond a bad apples approach, with media sensationalism, to better understand and address the inherent risks of modern health care. As a national body, it is Council s responsibility to ensure that the impetus for safety and quality improvement is maintained and that change and innovation, wherever it happens, is fostered and supported. While there are many exemplary practices for improving patient safety in place, they are on the whole individual and isolated efforts. It will take systemic change on a national basis to effect change of the magnitude needed and this can only be realised through strong leadership and a national approach. I welcome the strong support of Health Ministers for the work of the Council and commend this report to you. Professor Bruce Barraclough Chair July 2001 Reference Safety and quality in Australian healthcare: making progress MJA 2001; 174: (i)

6 Performance Summary The following is a summary of the progress and significant achievements made by Council. Safety First Report The Australian Council for Safety and Quality in Health Care presented its first report to Health Ministers in July The Council sought funding for a five-year national program of work to improve safety and quality in the Australian health care system. A Strategic Plan In August 2000, Council convened a Strategic Planning Workshop to formulate a vision for a safer health care system. During the workshop, Council members identified the characteristics of a safe, high quality health system and set priorities for Council action. These priorities formed the basis of the National Action Plan 2001 and provided a framework for the first year s program of work. Special Medical Seminar In November 2000, the Council, together with the Australian Aviation Psychology Association and the NSW Council for Quality in Health Care, sponsored a special medical seminar as part of the Fifth Australian Aviation Psychology Symposium. The seminar provided an opportunity for health care practitioners to learn from and build on research undertaken in the aviation industry and to translate these experiences to improving safety in health care. National Action Plan 2001 In February 2001, Council and the Commonwealth and NSW Health Ministers launched National Action Plan 2001, the first nationally agreed blueprint for change, which identified the main issues to be addressed and actions to be taken to improve safety and quality in health care delivery in Australia. Communications In February 2001, the Council launched the Safety and Quality website to promote Council s activities and to provide a mechanism for feedback from health care professionals and community members who are interested in Council's work. First National Report on Patient Safety In February 2001 Council commissioned the first in a series of patient safety reports to raise community awareness and understanding of the issues and challenges in improving the safety of health care. Survey of Health Care Professionals In April 2001, a survey of health care professionals was commissioned, as part of the consultative process, to identify barriers to and opportunities for the safer delivery of health care in hospitals. Consumer Conference and Workshop In May 2001, a conference Improving Health Services through Consumer Participation, jointly sponsored with the Consumer Focus Collaboration, and a workshop A Vision for a Safer Health Care System, provided an opportunity to undertake national consultation with grass roots consumer groups on ways to improve health care services. 1st Asia Pacific Forum on Quality Improvement in Health Care The Council is collaborating with the British Medical Journal Publishing Group (UK) and the Institute of Healthcare Improvement (US) to organise the 1 st Asia-Pacific Forum on Quality Improvement in Health Care. The Forum, in September 2001, will bring together, for the first time in Australia, international and national leaders in quality in health care, to exchange practical ideas and tools for improving work environments and practices. (ii)

7 Future Directions The following provides an indication of the future work that the Council will be undertaking. Using data to better identify, learn from and prevent error and system failure Implementing key elements of an agreed national approach to using data to make health care safer including: establishing nationally consistent functional specifications for incident monitoring in health care facilities enhancing existing national morbidity and mortality data sets developing national processes for review of patient deaths producing national specifications for action on adverse events which lead to serious patient harm developing national strategies on medication error and health care acquired infections strengthening existing review mechanisms such as device reporting systems and clinical audit consulting on a vocabulary of key safety and quality terms Supporting those who work in the health care system to practise safely developing core standards for health care safety as part of organisational accreditation consulting on the development of national guidelines for credentialling coordinating national actions to enhance the integrity of qualified privilege schemes and public reporting of outcomes supporting a national approach to specialist vocational registration Redesigning systems and facilitating a culture of safety establishing a national collaborative project to reduce medication errors in health care facilities supporting national work on curriculum development and educational strategies on system safety, human factors and communication developing national standards and educational support for open disclosure to consumers when things go wrong initiating a Safety Innovations in Practice program to support locally based safety improvement initiatives establishing a national series of fora and seminars drawing on Australian and international expertise Actively promoting opportunities for consumer participation and feedback supporting nationally applicable models of successful partnerships and teamwork involving consumers and health care providers to improve patient safety enhancing opportunities for consumer feedback improving information about health care safety for the community (iii)

8 RECOMMENDATIONS Health Ministers are asked to agree to the following recommendations noting that the Council intends to consult widely on their implementation. It is recommended that Health Ministers: 1. Reaffirm a strong commitment to improving the safety and quality of health care as the core focus for ongoing reform of the health care system in Australia and agree to play a leading role in implementing agreed national actions; 2. Commit further funds of $12 million for the Council s second year program of work and endorse the process for recognising in kind contributions from all jurisdictions as part of this, and future funding commitments (Attachment 1); 3. Agree to make the full Council report publicly available; 4. Actively support the Council in hosting the 1 st Asia-Pacific Forum on Quality Improvement in Health Care and take steps to ensure the greatest possible participation across Australia; 5. Note general progress in key priority areas in particular: a) The planned public release of the First National Report on Patient Safety and the intention to publicly report on a regular basis on issues, achievements and challenges for improving health care safety (Attachment 2); b) The proposed national approach to the use of data to improve the safety of health care (Attachment 3); c) The development of a vocabulary of safety and quality terms; d) The planned development of core safety standards for health care services and facilities and Council s intention to make further recommendations to Health Ministers about mandatory requirements (Attachment 4); e) The development of draft national guidelines for credentialling of health care professionals to include performance assessment (Attachment 5); f) The development of national principles relating to qualified privilege (Attachment 6); g) Directions for a national approach to specialist vocational registration (Attachment 7); h) The development of national standards and educational activities to support more open disclosure to patients and their carers when thing go wrong; i) The development of educational programs to increase knowledge of system safety, human factors and communication; j) Progress on specific initiatives in relation to improving medication safety and reducing health care acquired infection. (iv)

9 TABLE OF CONTENTS Page Statement from the Chair Performance Summary i ii Future Directions iii Recommendations Introduction Choosing Appropriate Strategies Lessons Learned Partnerships Priority Areas Achievements and Future Directions Using Data to Better Identify, Learn from and Prevent Error and System Failure Supporting Those who Work in the Health Care System to Practise Safely Redesigning Systems and Facilitating a Culture of Safety Actively Promoting Opportunities for Consumer Participation and Feedback Council Finances Establishment and Administration Funds Project Funds Commissioned Projects Financial Principals, Processes and Protocols Appendices 1. Overview of the Council 1.1 Council at a Glance 1.2 Terms of Reference 1.3 Membership 1.4 Meeting Activities of the Chair and Deputy Chair 3. Findings of a Survey of Health Care Professionals 4. Communications iv (v)

10 List of Tables 1. Summary of Progress: Using data to better identify, learn from and prevent error and system failure 2. Summary of Progress: Supporting those who work in the health care system to practise safely 3. Summary of Progress: Redesigning systems and facilitating a culture of safety 4. Summary of Progress: Actively promoting opportunities for consumer participation and feedback 5. Projects commissioned in List of Figures 1. Dimensions of decision making for systems improvement 2. Indicative budget for Council activities. 3. Procurement process for Council 4. Council structure List of Attachments NOTE: These are associated reports that are available separately 1. Process for Recognising In Kind Contributions from Jurisdictions 2. First National Report on Patient Safety 3. Safety in Numbers A Technical Options Paper for a National Approach to the Use of Data for Safer Health Care (Work in Progress) 4. Core Standards for Health Care Safety (Consultation Paper) 5. Credentials and Clinical Privileges Guidelines (Working Draft for Consultation) 6. The Public Interest in Health Care Qualified Privilege (Issues Paper) 7. A Model for Medical Registration (vi)

11 INTRODUCTION In January 2000, Australian Health Ministers set up the Australian Council for Safety and Quality in Health Care to provide national leadership for a collaborative approach to improving the safety and quality of health care. An overview of the Council, including its Terms of Reference, membership, working groups and meeting dates, are at Appendix 1. This report, Safety in Practice Making Health Care Safer, reports on the progress of the Council s work since its report to Health Ministers in July 2000, its significant achievements over the past year, and its work program for the future. It follows Council s first report to Health Ministers, Safety First, which proposed the focus, direction and priorities of Council s work over its five-year term. Further detail on the activities of the Chair and Deputy Chair of Council can be found at Appendix 2. The importance of Council s safety first focus was affirmed by the subsequent launch of the National Action Plan 2001 in February 2001, which allowed Council to embark on its program of work. Over the past 12 months, Council has undertaken consultations both with people working in the health system and consumers of health care to determine the best way forward. Consumers have told Council that they expect that all who work in or have responsibility for the health care system will actively promote health care safety and take all necessary steps to minimise risks to patients. This is seen by many in our community as a foundation for maintaining and strengthening public confidence and trust. Consumers have also told Council that safety is not just about freedom from accidental injury but also a broader sense of being in safe hands throughout an episode of health care. Consultation with health care professionals has indicated that most support the importance of a safety first focus and find resonance with the guiding ethos of first do no harm. Many recognise that there are ways in which health care safety could be improved, although there is by no means consensus about what should be done to fix the problems. Appendix 3 outlines in more details the findings of this pilot market research. Choosing Appropriate Strategies The Council is leading a comprehensive and ambitious program of national work to improve health care safety in Australia. At is simplest, Council believes that to achieve its objectives: systems need to be simplified and redesigned; data needs to be used more effectively for making improvements; health professionals need to be given greater support to make health care delivery safer; and consumers need to be consulted on, and actively involved in, key areas of work. It is clear that there is no magic bullet single answer for fixing health care safety. The choice of strategies always involves trade-offs, and because of their complexity the right mix of levers for change is not always clear. Figure 1 illustrates some of these dimensions. How these are addressed represent both opportunities for change and potential barriers to improvement. 1

12 Accountability to build responsibility Accountability to lead to blame Voluntary Mandatory Safety & Quality Accessibility Open information Privileged information Individual Team Top down Bottom up Local National Figure 1: Dimensions of decision making for systems improvement Lessons Learned During the past 12 months the following important lessons have been reinforced for the Council. Systems improvement focus While acknowledging the complexity of the issues involved, the Council believes that an emphasis on systems improvement is a critical foundation for change and indeed, will become more so, as modern health care involves increasingly complex systems of care. A systems focus does not detract from the importance of accountability for actions from those who work in and lead the health care system. For a relatively small but important number of patients, this may involve health care providers being held appropriately accountable for negligent actions. However, for the vast majority of accidents, mistakes and system failures which occur, the Council believes that the current blame-based approach, only serves to drive problems underground and are simply not helpful in efforts to make health care safer. 2

13 A Systems Approach The Council s work program recognises the need for change at four levels of health care. 1. The patient and their interactions with health care professionals. Effective and open communication is essential. Equally important is getting valuable feedback from consumers and ensuring that this is acted upon to make health care safer. 2. The environment of care in which this interaction between a health care provider and consumer takes place. This could be a hospital ward, a doctor s office or a person s home. The design of the environment to ensure that it is as risk free as possible is critical at this level of change. 3. The organisational context facilitates much of the environment of care and as such is an important focus for our efforts to improve safety, for example, through standard setting and external assessment of the organisational environment. 4. The system as a whole which can be seen as incorporating safety as core business of the system, valuing safety, supporting those managing a safe environment and those providing safe care. Greater Openness The Council also believes that greater openness is needed in our efforts to improve health care safety. At its heart, this involves better communication between health care providers and patients and managers, especially when something unexpected happens. A summary of Council s communications is at Appendix 4. An Approach With Clout Thirdly, the Council believes that improving health care safety requires that we should take an approach with clout. This means developing incentives for making health care safer as we know that for many busy health care providers there is little opportunity to look beyond their day to day demands to think about how things could be done better. However, it also means that we should not shy away from sanctions and consequences when known risk factors and problems are not appropriately addressed. Collaboration Finally the Council recognises the importance of involving all players. Collaboration is essential for our program of work to succeed. No one group can build a safer health care system on their own and the size of the task ahead should not be underestimated. The Council has worked closely with States and Territories and has set up a senior Quality Officials Forum from Commonwealth, State and Territory health departments to support and inform its work. The Council has also established working groups in priority areas with wide involvement of experts from across the health care spectrum. Appendix 2 outlines details of these groups. 3

14 Partnerships The Council has developed partnerships with other national agencies and bodies to take forward priority work including: Australian Institute of Health and Welfare - collaboration on the First National Report on Patient Safety, a vocabulary of key definitions and joint work on the development of a national approach to using data to make health care safer; National Institute for Clinical Studies - planned joint work on initiatives to implement evidence into clinical practice; Therapeutic Goods Administration - joint work on the development of a national approach to using data to make health care safer; National Health and Medical Research Council collaboration on evidence review for safety improvement; and National Health Information Management Advisory Council - proposed collaboration on health information management initiatives. 4

15 PRIORITY AREAS ACHIEVEMENTS AND FUTURE DIRECTIONS The following sections outline achievements and future directions made in the four priority areas identified by Council, namely: 1. Using data to better identify, learn from and prevent error and system failure; 2. Supporting those who work in the health care system to practise safely; 3. Redesigning systems and facilitating a culture of safety; and 4. Actively promoting opportunities for consumer participation and feedback. 5

16 Using Data to Better Identify, Learn from and Prevent Error and System Failure Anticipated achievements (Source: Safety First, Report to the Australian Health Ministers' Conference, 27 July 2000, Australian Council for Safety and Quality in Health Care) Actual outcomes Foundation elements of an agreed reporting approach in place including: agreement on the scope and components of a national approach to incident and adverse event monitoring and reporting; progress on agreeing consistent data definitions; established governance and communication strategy; and strategies to promote sustainability and best use of existing core national data sets. Following background research, the following elements of a national approach to reporting are being pursued: nationally consistent functional specifications for incident monitoring in health care facilities; work on enhancing the quality and accessibility of existing national morbidity and mortality data sets; enhancing processes for review of patient deaths; national specifications for action in relation to adverse events which lead to serious patient harm; leading national work to address known problems such as medication error and health care acquired infections; enhancing the value of existing review mechanisms such as device reporting systems and clinical audit; the development of a First National Patient Safety Report; and consultation on a vocabulary of key safety and quality terms. Table 1: Summary of Progress: Using data to better identify, learn from and prevent error and system failure 6

17 Using Data to Better Identify, Learn from and Prevent Error and System Failure The quality, usefulness and accessibility of data that are essential to make health care safer continues to be a barrier to improving safety. The great majority of health care professionals and managers are committed to taking all necessary steps to ensure that patients receive the safest and highest quality care possible, but too often their efforts are limited by an absence of accessible data about patient care needed for making improvements and to support decision making in the complexity of modern health care environments. The Council s work on data and information is therefore being designed to ensure that: effective systems are in place to identify and report incidents and adverse events, which have the confidence and trust of people working in the health care system and the community; information about incidents and adverse events are carefully analysed to identify contributing factors; and there are ways of closing the loop, that is, quickly disseminating and acting upon information about potentially preventable contributing factors to better manage hazards and risks and improve systems of care. The key focus of work in this priority area it to establish a comprehensive national approach to using data to identify, learn from and prevent error and system failure. It is about ensuring that information about incidents and adverse events is carefully analysed to identify contributing factors and acted upon to better manage hazards and risks and improve systems of care. The Council s work in this area aims to: provide information that helps to improve the safety of health care; encourage greater openness about patient safety and building public confidence that all necessary steps are being taken to promote the safety of health care; and promote a risk reduction approach to health care and effective accountability for performance. Achievements The following achievements have been made against this priority area: Safety in Numbers A Technical Options Paper for a National Approach to the Use of Data for Safer Health Care As a first step in developing a national approach to better using data for safety improvement, the Council has compiled a summary document on existing national sources of data and the gaps and limitations of those data entitled Safety in Numbers (Attachment 3). This report highlights the fact that there is no single source of statistics that provides a precise measure of the frequency or magnitude of adverse events. It also identifies the need for investment to improve different data collection and analysis methods to ensure that a comprehensive picture of things that can and do go wrong can be obtained. 7

18 First National Report on Patient Safety In the absence of other reliable sources of information, much of the community s understanding of health care safety issues is derived from often sensationalist media reporting of errors and systems failures in health care. This reduces that very fragile value, trust, which underpins all health care activities. Council has produced a report entitled First National Report on Patient Safety in an attempt to balance this picture by providing an overview of health care safety in Australia (Attachment 2). Using a plain English style and case studies, the report aims to raise community awareness and understanding of the challenges that face the health care industry. It also outlines approaches, within a risk management framework, for reducing the occurrence and impact of preventable system failures that could result in harm to patients. The Council intends to distribute this report widely, in summary format, and to produce a similar report on a regular basis. Vocabulary of Key Safety and Quality Terms A lack of consistent safety and quality terms means that developing a more nationally coordinated approach to using data for improvement, and communicating effectively with health care professionals and the community about health care safety and quality, can be confusing and difficult. In order to address this problem, the Council is researching and compiling a vocabulary of key safety and quality terms as a basis for broader consultation and discussion. In the longer term, the Council may also seek to have some of these terms included in the National Health Data Dictionary. Surveillance of Health Care Acquired Infection Health care acquired infections can result in serious consequences for individual patients and place a significant burden on the health system. The financial and social costs of health care acquired infections are difficult to measure and the lack of comprehensive data makes estimates difficult. The Council, in discussion with key stakeholders, is proposing a national approach to the reduction of health care acquired infection with the emphasis on surveillance and improved collection and use of data for clinical practice improvement to minimise infections. Collaborative strategies and action will build on the considerable work of State and Territory jurisdictions and professional groups such as the Australian Infection Control Association. The work of the Council will link to national initiatives on the development of an integrated system of surveillance and monitoring antibiotic resistance in humans and animals arising from the recommendations of the Joint Expert Technical Advisory Committee on Antibiotic Resistance (JETACAR). The Council will sponsor a nationally coordinated approach to dealing with health care acquired infection and will engage a range of expertise in epidemiology, infection control, clinical practice, clinical process improvement and standards development to establish national standards for health care acquired infection surveillance systems. Council expects to develop standards for a national hospital infection surveillance program. 8

19 Proposed outcomes include: agreed national standards to promote integration of data for improvement at a clinical level; improved national consistency of data for surveillance and benchmarking purposes; support at a local level for collection, analysis, and use of data for clinical practice improvement; opportunities for greater collaboration and exchange of ideas and approaches nationally; and appropriate links to national and state initiatives on surveillance and monitoring of health care acquired infection and antibiotic resistance. Future Directions The Council believes that a comprehensive national approach to data and information for safety improvement requires us to have systems that will, in the future, provide information at three different levels: information on adverse events that contribute to patient death or serious disability; information on adverse events that result in less serious harm to patients, especially those that occur frequently and those which help to understand system problems; and information on near misses ie those system failures which could have led to patient injury but were detected and intercepted before this occurred. In order to strive towards this achievement, the Council has identified the following key targets and action areas to build the elements of a comprehensive national approach: developing nationally consistent functional specifications for incident monitoring in health care facilities which support aggregation of incident data for analysis and action at a national level; commissioning work on enhancing the quality and accessibility of existing national morbidity and mortality data sets for safety improvement purposes; enhancing processes for review of patient deaths which may be attributable to an adverse event including work with Colleges on national protocols, identifying areas for improvement in completion of death certificates and working with Coroners to improve the value of coronial data; developing national specifications for action in relation to adverse events which lead to serious patient harm; leading national work to address known problems such as medication error and health care acquired infections; enhancing the value of existing review mechanisms such as device reporting systems and clinical audit; and developing strategies for measuring, improving and reporting on system-wide performance. The Council intends working closely with key national bodies including the Australian Institute for Health and Welfare (AIHW), National Health Information Management Advisory Committee (NHIMAC) and Therapeutic Goods Administration (TGA) on the implementation of these actions. 9

20 Supporting Those who Work in the Health Care System to Practise Safely Anticipated achievements (Source: Safety First, Report to the Australian Health Ministers' Conference, 27 July 2000, Australian Council for Safety and Quality in Health Care) Actual outcomes Foundation elements of an agreed approach to clinical and corporate governance in place including: development of national standards in relation to clinical governance and national audits; establishment of a communication and uptake strategy and identification of lead implementation sites; and agreed priority areas for reform for legislative, regulatory and standards frameworks. Work has commenced on elements of the strategy in this area including: scoping work on directions for a national approach to clinical audits; policy directions on standard setting and accreditation in health care; draft national guidelines for credentialling; national directions for qualified privilege; and national approach to specialist vocational registration. The Council intends to consult widely on the elements of this strategy. Table 2: Summary of Progress: Supporting those who work in the health care system to practise safely 10

21 Supporting Those who Work in the Health Care System to Practise Safely The key focus of work in this priority area is to strengthen the effectiveness of mechanisms to ensure starting and ongoing competence and performance of health care professionals and to ensure the organisational and clinical environments in which they work support safe practice. Strategies to progress this work include: policy direction on standard setting and accreditation in health care; consultation on draft national guidelines for credentialling; national directions for qualified privilege; and a national approach to specialist vocational registration. Achievements The following achievements have been made against this priority area: Core Safety Standards There has been much discussion about the need to review the comprehensiveness and effectiveness of current safety standards in organisational accreditation processes and to identify priority areas for standards revision and development to improve safety of care. In light of these discussions, the Council has developed a consultation paper entitled Core Standards for Health Care Safety (Attachment 4). Credentialling and Clinical Privilege Guidelines The effectiveness and adequacy of credentialling processes has been identified as an important area for improvement (Final Report of the Taskforce on Quality in Australian Health Care 1996). Credentialling typically involves the formal processes at a facility level which are used to determine what types of work a health care provider can undertake in that facility. While guidelines have been developed in a number of disciplines and local areas, the Council has identified the need for nationally agreed guidelines that incorporate procedures for ongoing performance assessment. With the leadership of Queensland Health, the Council has developed a working draft paper entitled Credentials and Clinical Privileges Guidelines (Attachment 5). The Council is initially focussing on the medical profession with a view to broadening and adapting these guidelines this to include all health care professional groups that have independent clinical decision making responsibility. Qualified Privilege Schemes For the past decade most jurisdictions have had some form of qualified privilege legislation which provides clinicians with confidentiality of discussion about certain information collected during health care safety and quality activities. The rationale for introducing this type of legislation has been that, by eliminating the legal risk of disclosure of certain information, it would encourage health care professionals to participate in safety and quality improvement activities. 11

22 More recently, there has been significant community debate about the public interest in such schemes and the appropriate balance of protection and disclosure. Over the past year, the Council has sponsored discussion among jurisdictions and professional groups about the rationale and ongoing need for qualified privilege, the effectiveness of current legislative schemes, and areas for improvement. A key outcome from these discussions is recognition of a continued need for qualified privilege to encourage greater participation by health care professionals and managers in open and honest review of clinical processes. Based on this view, the Council has developed an issue paper entitled The Public Interest in Health Care Qualified Privilege (Attachment 6) which suggests national principles to underpin qualified privilege and promote greater national consistency where appropriate. The Council will be taking forward a number of actions, in conjunction with jurisdictions, to maintain the integrity of current qualified privilege schemes, in particular, to promote more open disclosure through effective reporting of outcomes of privileged activities. Vocational Registration At present, the links between the criteria to obtain vocational registration and assurances that registered doctors are practising safely and effectively are not strong. To complement and give further impetus to a recent Australian Medical Council and Council of Presidents of Medical Colleges initiative to address this issue, the Council asked the New South Wales Medical Board to recommend ways in which the competence and performance of doctors could be better reflected in the criteria used when granting vocational registration. In response to this request, the New South Wales board has written a paper entitled A Model for Medical Registration (Attachment 7), on behalf of the Council. When organised in a context in which safety and quality of care are paramount, it is suggested that medical registration should achieve the following: identify vocational qualifications and ensure that doctors work within their areas of qualification and demonstrated competence; require continuing professional development and recency of practice and directly link these to renewal of medical registration; and be nationally consistent and portable across all Australian jurisdictions. Future Directions Accreditation In consultation with key players, the Council plans to establish a program of work to: identify areas of health care safety which should be the focus of core standards; review existing standards both within Australia and internationally to identify gaps and areas for development; revise and develop new standards as required; and develop processes for uptake and implementation through accreditation and other external assessment processes, including recommendations to Health Ministers on mandatory standards. 12

23 Credentialling Work will be progressed to develop national guidelines on credentialling of health care professionals to include performance assessment through: consultating widely with key players on draft national guidelines for credentialling; developing strategies to support implementation and uptake of guidelines (such as appropriate tools for performance assessment and mechanisms to enable the constructive response to outcomes of credentialling processes); adaptating/applying guidelines across a range of health professional groups; and includ ing credentialling standards as part of facility accreditation. Qualified Privilege Future work to nationally maintain the integrity of existing qualified privilege schemes and, in particular, the effectiveness of reporting outcomes and improvements resulting from privileged activities will include: designing information strategies (for example, an information brochure and protocols to support participants to effectively use the privilege and better meet their obligations) to educate both the public and participants about the purpose and scope of qualified privilege schemes; producing a report on the objectives, processes and achievements of qualified privilege and the outcomes and improvements resulting from projects protected under qualified privilege legislation; and clearly articulating the specific scope of protection intended to be provided by each qualified privilege scheme. Vocational Registration Work will continue in conjunction with the Australian Medical Council and the Committee of Presidents of Medical Colleges to develop a national approach to specialist vocational registration. 13

24 Redesigning Systems and Facilitating a Culture of Safety Anticipated achievements (Source: Safety First, Report to the Australian Health Ministers' Conference, 27 July 2000, Australian Council for Safety and Quality in Health Care) Actual outcomes Foundation elements of agreed approach to redesigning systems and facilitating a culture of safety in health care in place including: agreed national approach to promoting culture change; establishment of lead implementation sites for clinical decision support; development of a national conference on safety and quality improvement; and development of undergraduate and joint college education modules on safety and quality. While changing culture and system redesign is integral to Council's work generally, specific progress in this area includes: a survey of health professionals to identify barriers, threats and opportunities for improving the safety of health care; a special medical seminar as part of the 5th Aviation Psychology Symposium to explore how the management of safety in the aviation industry could be applied to health care; scoping work on a clinician led, multi disciplinary medication safety project; co-hosting and organising a world class conference (1st Asia Pacific Forum on Quality Improvement in Health Care) bringing together leaders in quality improvement; scoping work on the development of national curricula in systems safety, human factors and communication; and developing national principles to support open disclosure of adverse events. Table 3: Summary of Progress: Redesigning systems and facilitating a culture of safety 14

25 Redesigning Systems and Facilitating a Culture of Safety The key theme of work in this area is redesigning systems of care within health care to make them safer. The Council recognises that, when it comes to making health care safer, doctors, nurses and other health care professionals are often let down by outmoded and poorly designed health care systems which can no longer cope with the complex demands of modern health care. Systems redesign goes hand in hand with cultural change which is guiding all aspects of the Council s work program. Of particular importance is the need to move beyond blaming health care professionals when things go wrong to look at how systems and processes of care can be redesigned and made simpler to help prevent and mitigate mistakes and system failures. This includes strategies to work with frontline health care professionals and managers in areas such as information technology to support clinical decision making, strengthened team work and communication within health care, improved educational support on systems safety and risk management and strategies to promote greater openness when things go wrong. Strategies to progress work in these areas include: special medical seminar at the 5 th Aviation Psychology Symposium, November 2000; 1st Asia Pacific Forum on Quality Improvement in Health Care; national standards and education to support open disclosure; medication safety; and education strategies. Achievements Special Medical Seminar In November 2000 the Council, together with the NSW Council for Quality in Health Care, sponsored a special medical seminar as part of the 5th Australian Aviation Psychology Symposium. Guest speakers of international repute from aviation and health care addressed the seminar, which was organised in response to strong interest from health care professionals in how errors and adverse events are managed in the aviation industry and the potential application to the health care industry. The final workshop session resulted in recommendations for improving the management of adverse events at all levels of the health care system being proposed. These recommendations provided clear guidelines and priorities for Council s program of work in key areas of safety and quality. A report Lessons for Health Care: Applied Human Factors Research was published in January 2000 and has been widely disseminated. The 1st Asia Pacific Forum on Quality Improvement in Health Care This Forum is a key Council project, spearheading work on cultural change and systems redesign to improve the safety and quality of Australia s health care system. The Forum will be held in Sydney September 2001 and will bring together, for the first time in Australia, a unique gathering of quality improvement leaders. The aim of the Forum will be to raise awareness of safety and quality improvement across a range of audiences, encourage cultural 15

26 change and the uptake of issues across the health system, and promote understanding of practical improvement tools. The Forum a world class event being organised in collaboration with the British Medical Journal (UK) and Institute for Healthcare Improvement (USA) - will inspire and provide the practical skills for those in health care to improve their work practices and environments. Speakers at the Forum are among the world s most influential thinkers on organisational psychology, risk management, and quality improvement with a broad range of experience internationally. It is envisaged that the 1st Asia Pacific Forum on Quality Improvement in Health Care will be the first in a series of similar meetings in our region. Open Disclosure Active management of adverse events through timely and appropriate information flows is vital to drive and support improvements in the safety and quality of our health care system. A key step in the process is to encourage greater openness between health care providers, patients and their carers when things go wrong. While there are standards that focus on effective communication between health professionals and patients/consumers, they do not focus on communication following an adverse event. The aim of this initiative is to develop national standards and guidelines that will promote a consistent approach to open disclosure of adverse events and to saying sorry. This will enhance communication processes when something has gone wrong. This project commenced in February 2001 under the auspice of the Consumer Working Group of the Council with lead work being undertaken by the Department of Health and Human Services, Tasmania. There has been strong interest from across the health sector in this activity. Consultation with a wide range of consumer, professional and provider organisations has been undertaken to: review the evidence of the value of open disclosure of adverse events; review the strengths and weaknesses of communication models dealing with adverse events currently in use throughout Australia; develop principles to underpin open disclosure of adverse events; and identify where there is a need for educational and other resources. Medication Safety Medication error is one of the most common causes of adverse events in health care. The Australian Patient Safety Foundation reports that 11.6% of incident reports relate to problems with omission, wrong dosage or wrong medication. There is considerable evidence from both within Australia and overseas about effective interventions to reduce the risk of medication errors (for example, the work of the Institute of Healthcare Improvement on breakthrough collaborative projects to improve medication safety). 16

27 The Council intends to initiate a national, multi-disciplinary change project to achieve measurable reductions in medication errors in Australia. This will help to develop and evaluate the best methods to help clinical teams and health care organisations to prevent medication errors. This will also help to develop national standards and guidelines to improve systems for medication management. The Council has established a small working group, jointly chaired by Dr David Brand and Professor Ric Day (Chair of the Pharmaceutical Health and Rational Use of Medicine Committee) to take this work forward. A consultative workshop with stakeholders was held in July 2001 to ensure that the Council work links with relevant national groups and builds on related bodies of work. Educational Strategies Supporting health professionals and managers through appropriate education is one of the foundation elements of redesigning systems and facilitating a culture of safety in health care. Other industries such as aviation and the nuclear industry have well established approaches to staff education and training for dealing with adverse events and rehearsing for system failures or errors. There are currently only limited learning opportunities for health professionals and managers in this area. To address this gap, the Council is commissioning work on systems safety, human factors and communication in health care for integration into undergraduate and postgraduate education and training, and the development of education and training strategies for innovative, teambased approaches in clinical settings to risk management and dealing with systems failure. Future Directions Medication Safety The Council identified medication safety as a priority area for 2001 and is scoping the possibility of a national collaborative project using a lead health service model. The main aim of the project is to reduce medication error through system and process redesign and strong local collaboration/clinical leadership. The project will focus on developing appropriate standards and guidelines to support safer medication use nationally and will build on both Australian and international initiatives to reduce medication error. The project will link closely with other bodies addressing quality use of medicines issues. Educational Strategies The Council is commissioning work on: the development of core curricula on risk management, human factors and a systems approach to safety and communication and teamwork within complex systems for integration into undergraduate curricula for medical and nursing schools nationally with wider application to other health science disciplines; the development and implementation of similar education modules or programs for inclusion in postgraduate programs for health care professionals and managers, which will 17

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