10 February 2012 Mr Bill Lawrence AM Acting CEO Australian Commission on Safety and Quality in Health Care GPO Box 5480 Sydney NSW 2001 Email: goals@safetyandquality.gov.au Dear Mr Lawrence RE: Australian Safety and Quality Goals for Health Care: Consultation paper The Royal College of Pathologists of Australasia (the College) welcomes the opportunity to comment on this important document. Overall, the College is supportive of the contents of the document however would like to note that pathology is vital to the quality of healthcare and is related to almost all goals of diagnosis and monitoring and that it is disappointing that pathology is not mentioned more frequently in the document. The College encourages the Commission to ensure that the overarching impact across the board on all of the Goals of pathology and the pathologist workforce is taken into account when developing the Goals further. Some examples of this are given below, with reference to the three Draft Goals and their priority areas: Goal 1. Safety of care: That people receive their health care without experiencing harm. Initial priorities are to: reduce harm from adverse medicines events and improve quality use of medicines College comment: Monitoring of adverse harm from medicines includes pathology testing ranging from liver and muscle toxicity of statins, to renal toxicity of antibiotics, to bone marrow suppression and anaemia and hormonal disturbances caused by medications such as anticonvulsants and anti-arrythmics. reduce harm from healthcare associated infections through effective infection control and antimicrobial stewardship. College comment: The identification of the agents of infection is performed by pathology and hospital infection control depends on the results on pathology analysis and strategies and governance are often dependent on advice from microbiology specialist pathologists. The inappropriate prescribing of antibiotics is an area of major concern and responsibility in pathology laboratories where the testing for drug sensitivity and resistance is reported and monitored. Page 1 of 5
Goal 2. Appropriateness of care: That people receive appropriate, evidence-based care. Initial priorities are for: people living with type 2 diabetes College comment: Type 2 diabetes is diagnosed by pathology (blood glucose) and monitored by pathology ( HbA1c < 7% ) and the management of complications are also dependent on pathology tests (eg urine microalbumin, cholesterol management goals). Pathologists are key specialists in determining the appropriate timing and test combinations for patients with this chronic condition. people with acute coronary syndrome or stroke. College comment: The modern definition of acute coronary syndrome is primarily dependent on the new Troponin blood test which has revolutionised the assessment of cardiac damage and risk. The diagnosis and its risk are heavily dependent on the integrity of pathology testing. While this seems to be neglected in the discussion of this issue in this consultation document, it may be because it is taken for granted, which is why the integrity of testing becomes vital. Any cardiologist would be aware of the importance of sample integrity to the management of this condition. Goal 3. Partnering with patients and consumers: That there are effective partnerships between patients, consumers and healthcare providers and organisations at all levels of healthcare provision, planning and evaluation. College comment: The interaction of the patient with pathology collectors and the communications in pathology reports are some of the most common patient interactions in modern medicine. Pathology laboratories partner with doctors and patients in providing feedback on their diagnosis and ongoing management. The integrity of that information is a critical element that is immediately visible to patients. The College responses to specific consultation questions are outlined below. 1. How do you think national safety and quality Goals could add value to your existing efforts to improve the safety and quality of care? Pathology and pathologists are more likely to be able to assist others in achieving these Goals. Laboratory medicine itself is already closely monitored by a highly regulated and effective accreditation system involving NPAAC, RCPA/NATA, RCPA/QAP etc. It is through this rigorous process that the College is able to identify the priority areas described below. 2. Do you agree with the topics that have been included as Goals and priority? In the main, the Goals are very relevant for patient care and safety, however the College has identified a number of other, potential priority areas: - one critical topic which is missing from Goal 1, is the correct identification of the patient. If a patient is not correctly identified, the ramifications can be severe and affect many areas of care from medication, pathology test results and treatment for the patient. In extreme cases incorrect identification of the patient can lead to death. The College proposes a specific priority area under Goal 1: Safety of Care related to collection and patient identification errors in pathology. A detailed response as to how this topic satisfies the criteria used to select the Goals is outlined below under point 6. Page 2 of 5
- variation in pathology reporting (eg different units, test names etc) has the potential to lead to misinterpretation and clinical error and this is being addressed through the Pathology Units and Terminology project (PUTS) being funded by the Federal Quality Use of Pathology Program. - variability in testing rates for different indications. We do not have a mechanism nationally to identify such variation, identify the causes, and take actions to improve the appropriate utilisation of tests. This is currently being addressed through the Pathology Electronic Decision support project being led by the College with the RACGP under the National Pathology Agreement. - Turnaround times for urgent samples (particularly from Emergency Departments). The ACHS data on Clinical Indicators to Improve the Quality of Healthcare for Pathology has consistently demonstrated that turnaround times for urgent samples show wide variation and, in a significant number of instances, poor performance (eg some facilities achieving targets for <50% of cases vs others achieving targets for >95% of cases). Significant adverse impacts include prolonged patient length of stay/overcrowding in Emergency. It would be useful to use the Collected to Validated and the Received to Validated times for Potassium (marker of chemistry turnaround times) and Haemoglobin (marker of haematology turnaround times). This would require only one additional measure to data sets that have been collected for a number of years. It also affords the opportunity to set reasonable targets based on the historical ACHS data. - Build on the previous work through the Commission for bridging the gap between coroners/forensic pathology and health departments regarding provision of autopsies and medico-legal clinical case review as well as the advice forensic pathologists provide to Coroners, the legal profession and health department consultative councils (surgical, anaesthetic and obstetric/perinatal etc). 3. What do you think about the specificity of the Goals and priority areas? Are they too broad or too specific? The College notes that the Goals appear broad and the priority areas are specific, which appears to be a reasonable approach. 4. Do you think there should be specific targets attached to the Goals or priority areas? If so, what form should a target take? The College supports the use of targets as they provide organisations with an ability to measure their performance relative to their peers. In order to achieve this, baseline data is required and should be utilised to measure improvements. Targets can be in the form of benchmarks, set at national level or standards that need to be met. 5. How do you see the Goals applying in different healthcare settings or for different population groups? The College has no specific response to this question. 6. What systems, policies, strategies, programs, processes and initiatives already exist that could contribute to achievement of the Goals? In pathology, the Royal College of Pathologists of Australasia (RCPA), Quality Assurance Programs (RCPA QAP) offer external quality assurance for medical (pathology) laboratories in Australia and internationally. In 2007, RCPA QAP piloted a program to measure pathology incidents and their impact on patient safety, with funding from the Quality Use of Pathology Program (QUPP). The Key Incident Monitoring & Measurement Systems (KIMMS) program is now an established QAP. Page 3 of 5
In regard to the collection of pathology incidents and misidentification in particular, there are many criteria for a priority area under Goal 1 satisfied. the impact on the health system in terms of issues such as the burden of disease, cost to the system and number of adverse events. The KIMMS program identifies 100,000 pathology identification incidents per annum but not all pathology laboratories in the country are monitored because currently the programme is optional. the existence of significant safety and quality problems, such as high levels of preventable harm and significant gaps between evidence and practice. Some incidents, such as transfusion sample errors, identified by laboratory quality systems are considered near miss incidents that could have been fatal. Others (e.g. haemolysed samples) at one end of the spectrum only cause sample recollection and delays in diagnosis and management but could, at the other end of the spectrum, lead to misleading diagnoses and management. the existence of a body of work that could be built on to make improvements, with broad agreement about clinical guidelines or other evidence-based strategies RCPA QAP has been providing external quality assurance programs to Australasian Pathology laboratories for over 30 years and is considered one of the most advanced, profession based quality programs in the world with participants in 40 countries. The KIMMS program has developed over the last 5 years to be the most advanced non-analytical quality assurance program available anywhere in the world. that the potential goal was amenable to national action at multiple levels of the health system The program already involves a hundred pathology entities that include statewide public pathology services and nationwide private pathology services. The program monitors not only the integrity of pathology episodes handled by pathology staff but also identifies incidents that occur at high frequencies across the health profile especially in critical clinical areas such as emergency departments and high dependency wards where the likelihood of errors seem to be greater. the likelihood that improvements would be achieved in a three to five year timeframe Participants have reported that risk areas identified in the KIMMS program can be addressed by both improved technology e.g. electronic patient identification, computerised pathology requesting and advances in sample integrity procedures in the laboratory. the existence of links to other national priorities The issue of sample identification has direct links with the National Blood Authorities concerns regarding life threatening transfusion reactions and the patient identification issues are directly related to the issues in pharmaceutical safety.these direct links are recognised in pages 14 and 15 of the document when discussing ways to reduce pharmaceutical adverse events. Page 4 of 5
the potential for the goal to be relevant across disease groups, sectors and settings of care There are very few clinical areas that aren t dependent on pathology tests. Even in psychiatry where pathology plays little role in diagnosis, drug levels and drug sideeffects are of major clinical importance. Similarly in orthopaedics, imaging may be more important for diagnosis than pathology, however surgery carries its own clinical risks and pathology tests are vital in assessing post-operative risk and recovery and, most certainly, for histological confirmation of soft tissue and bony lesions. the existence of measures, or potential to develop measures, that could be used to monitor progress. KIMMS has numerous measures that can be extracted from pathology information systems and software vendors are increasingly aware of the need for this facility in any new tenders and installations. The College has no specific comments on the last three questions (below) as these inputs are more appropriate to health service providers: 7. What do you think should be the initial priorities for action under the Goals? 8. How could the different stakeholders within the healthcare system be engaged in working towards achievement of the Goals? 9. What barriers exist in achieving the Goals? How could these be overcome? Once again the College appreciates this opportunity and, as the peak body responsible for quality and professional issues impacting on pathology and pathologists in Australasia, looks forward to ongoing input to development and implementation of the Goals. If you have any queries or concerns, please contact Dr Debra Graves, CEO on 02 8356 5830 or debrag@rcpa.edu.au. Yours sincerely Professor T Yee Khong President Page 5 of 5