The 309 page report of the 'Duckett Inquiry', ie
Targeting zero: Supporting the Victorian hospital system to eliminate avoidable harm and strengthen quality of care -
Report of the Review of Hospital Safety and Quality Assurance in Victoria states
This review’s terms of reference were expansive. The review was charged with examining whether the department has adequate systems for safety and quality assurance in place and (where systems were found to be inadequate) recommending how they might be improved to achieve contemporary best practice, as seen within other jurisdictions and internationally.
We were to assess the department’s systems for all in-hospital care, including mental healthcare, in both the public and private sectors.
In particular, we were asked to consider governance issues pertaining to the following issues:
• how the department should ensure that all boards of public health services and public hospitals are capable of providing appropriate local governance of safety and quality
• what systems the department should have in place to ensure robust monitoring of safety and quality at the hospital and health service levels including its approach to monitoring clinical governance at health services and its performance management framework to monitor clinical safety and quality in local health services
• what information about safety and quality should be reported to the department, and how the department should use that information including through public reporting
• whether the scope of the reporting to the department should be differently configured in public health services as compared with public hospitals, and what the scope of reporting for private hospitals should be.
We considered these along with information flow issues pertaining to:
• the role of the department in monitoring safety and quality in Victoria’s public hospital sector
• the type of information that should be available to boards and chief executive officers to assist in local monitoring of quality and safety
• the implementation of the Victorian Health Incident Management System (VHIMS) improvement project
• the relationships and information flows between the department and various other bodies with responsibility for the quality of care
• the relationship and information flows between the department and private hospitals regarding quality and safety.
We also examined clinical engagement and leadership issues pertaining to:
• the best approach for providing clinical leadership, advice and support to the new Chief Medical Officer that will strengthen the department’s oversight of quality and safety systems
• strategies to optimise the department’s response capacity and engagement in promoting an improvement culture among management and clinicians
• how the department should participate in and provide leadership to the safety and quality agenda, particularly in improvement, including through enhanced clinical engagement.
Our terms of reference note that some public hospitals are too small to have dedicated comprehensive safety and quality teams or clinical expertise in board members; many only have limited access to medical administration expertise. This is in some respects an anomalous feature of the Victorian system, which has a very large number of unremunerated independent boards for very small public hospitals in rural areas. We have not commented on the optimality of this model but rather have focused on recommending ways to strengthen it so the community can be assured of the same safety and quality of care in small rural services as in larger regional and metropolitan services.
A patient’s experience of care critically depends on the quality of their interaction with the clinical team. So too more broadly, does the overall safety and quality of the Victorian health system depend on clinicians, managers, boards and the oversight of the department. This report’s focus was governance of safety and quality of care in Victoria by the latter. We did not assess the governance of safety and quality within hospitals, except as it was affected by the overall system governance issues. Similarly, our recommendations focus on what the department can do to strengthen care. As we show, it can do a lot. Ultimately, however, it is those at the front lines of care that are best positioned to drive a system-wide transformation. Change of this kind needs to engage clinicians and be embraced by them.
The report's summary of findings is
1. Across all modern health systems, and despite concerted efforts, avoidable patient harm and variability in care occurs that no one should be prepared to accept. Avoidable patient harm means that patients suffered not through their illness or a lack of knowledge about treatment, but because of ineffective systems to keep them safe while receiving care. Variability of care indicates that valuable knowledge is not being shared and implemented widely, so that many patients are receiving care that diverges from best practice.
2. Australian research suggests that around one in every 10 patients suffers a complication of care during their hospital stay, with half of those complications avoidable. Most complications only have a minor impact on patients, but a significant minority end in permanent disability and death.
3. These complications are devastating for patients and families and significantly increase the cost of care across the system. All hospitals should be reducing them as a matter of priority. But doing so is not straightforward. For any health service, the challenge of achieving best practice in safety and quality is immense and requires grappling with clinical autonomy and patient variability. Decision making is all the more difficult because many of the costs of poor care don’t fall on the decision-maker (the hospital) but on patients, their families, other hospitals and the taxpayer more broadly. They can also be hidden, both within hospitals and from patients.
4. Further, complications are rarely the result of individual incompetence or malice. Rather, they arise within complex, high-pressure environments where mistakes easily occur and patients are often already frail and at risk of deteriorating. This inherent risk and complexity is why all hospitals need strong processes to minimise the risk and consequences of human error – and to ensure that when things do go wrong, problems are reported, reviewed and addressed. It is also why hospitals need strong oversight and support by system managers like the department. System managers can protect patients from serious failures in local safety and quality systems by monitoring hospital outcomes for signs of unsafe or low-quality care and by ensuring that hospitals take swift and appropriate action to address deficiencies. System managers can also support hospitals to strengthen the safety and quality of their care by using their vantage point and economies of scale to coordinate, encourage and facilitate improvement efforts across the system.
5. The review panel evaluated the way that the department, firstly, oversees the Victorian hospital system to ensure that it provides consistently safe, high quality care; and secondly, the way it supports hospitals to efficiently and effectively strengthen care. It found that the department is not adequately performing either role.
6. The panel found that the department’s oversight of hospitals is inadequate. It does not have the information it needs to assure the Minister and the public that all hospitals are providing consistently safe and high-quality care. For example, it does not have a functional incident management system for hospital staff to report patient harm. It has over-relied on accreditation when the evidence suggests that is not justifiable. It makes far too little use of the routine data at its disposal to monitor patient outcomes and investigate red flags suggesting poor care. Its expert committees are fragmented and many are not resourced to detect problems in a timely manner or to follow up to stop them happening again.
7. The department’s overarching governance of hospitals is also inadequate. In the public sector, the department expects hospital boards to ensure care is safe and continuously improving. However, it does too little to ensure that all boards are equipped to exercise this function effectively in the first place. In the private sector, where the department’s responsibilities for assuring safety and quality is roughly equivalent, the department relies to an even greater extent on local governance, and conducts no routine monitoring of patient outcomes or serious incidents. In both sectors, the department could and should be doing much more to ensure that hospitals do not provide care when it is outside their capability to do so safely.
8. Finally, the department’s support of hospitals to discharge their responsibilities with respect to safety and quality improvement has been inadequate. There have been fragmented efforts to support improvement but no continuous approach or sustained investment. Hospitals are often left to create their own approach to safety and quality improvement, leading to duplication of work and variation in quality. The department could be doing much more to encourage and facilitate hospitals to learn from each other and to ensure that ideas and innovations from one hospital spread to others.
9. Our review is not the first to identify these problems. Since 2005 the Victorian Auditor-General’s Office has conducted three performance audits on patient safety. The most recent found that the department is not effectively providing leadership or oversight of patient safety, is failing to adequately perform important statewide functions and is not prioritising patient safety. Some of the systematic failures noted in its 2016 audit were first identified over a decade ago in the 2005 audit.
10. The department has suffered a significant loss of capacity in recent years, in some cases creating or exacerbating these problems. Many dedicated departmental staff have called for change but lacked the authority or resources to achieve it. Budget cuts and staffing caps have gutted many departmental functions. The department has become increasingly reliant on external consultancies when the work would have been done better, and more cost-effectively, had the department retained capacity to deliver it in-house. A recent capability review noted the department has struggled to retain talent, so that capable leaders are thinly spread. It found a lack of long-term strategic planning and widespread stakeholder concerns that complacency has caused Victoria’s position as Australia’s leading health system to come into question.
11. The recommendations we have made are designed to change all this. Victoria should be seen as a leader in safety and quality. Our recommendations are broad, across the 10 major themes outlined below. We are confident that all are achievable and affordable. They will help to ensure all Victorians get the best of care. Many aspects of the report can be implemented quickly (within 12 months), some others may take up to three years.
In summary its recommendations are
1. Safety and quality improvement must be a core goal of the department and health system. To achieve this, we have recommended that:
• the Secretary and Minister each make clear public statements about the very high value they place on safety and quality
• the Minister seeks to amend the Health Services Act 1988 to ensure the Act’s objectives reflect this ambition and expectation
• the Secretary makes a clear public statement about the role of the department in the oversight of the health system and her statutory functions
• the Secretary establishes a specialist Office for Safety and Quality Improvement (OSQI) with responsibility for coordinating the efforts of clinical networks and relevant consultative councils and programs to drive system-wide improvement in safety and quality
• the department’s clinical networks set clear and measurable statewide safety and quality improvement goals, with the department publicly reporting on the system’s progress against them
• the department sets clear expectations for boards of all hospitals to have safety and quality as a core focus, with all boards setting and reporting on their progress against local improvement goals
• the department adopts national pricing reforms to strengthen executive focus on reducing hospital-acquired complications
• the department develops a detailed plan and timeline for implementing this report’s recommendations, and reports on progress against it to the Minister on a quarterly basis, with the Victorian Auditor-General’s Office conducting an audit of implementation by 2020.
2. All boards must be highly skilled, independent and effective. To achieve this, we have recommended that:
• the Minister pursues legislative change to extend public health service term-limit requirements and other appointment processes to public hospital boards
• the Minister establishes a Board Appointments Advisory Commission with responsibility for ensuring there is an adequate mix of skills (including substantive clinical governance and consumer representation) on every public hospital and health service board
• the Board Appointments Advisory Commission ensures board skill adequacy by evaluating applicants against an objective and transparent skills assessment framework, by requiring clinical governance training and ongoing development for board directors, by recommending that the Minister supply short-term delegates to boards where the skill mix is inadequate, and by recommending board amalgamation where long-term adequacy of skills cannot be achieved.
3. All hospitals should be held to account for improving safety and quality of care, regardless of their size or sector. To achieve this, we have recommended that:
• the Minister pursues legislative change to extend the statutory obligations for safety and quality in public health services to public hospitals
• the department monitors sentinel events and a common set of broader safety and quality performance indicators across public and private hospitals
• the Minister pursues legislative change to ensure an appropriate level of regulation for private services that are currently unregistered but provide care that carries a risk to patient safety.
4. The flow of information in the health system must ensure deficiencies in care are identified and focus attention on opportunities for improvement. To achieve this, we have recommended that:
• the government establishes the Victorian Health Performance Authority – an independent specialist safety and quality reporting body with responsibility for managing the department’s health data collections, developing the quality of clinical performance indicators, and improving access to clinical data by clinicians, boards, departmental staff and academic researchers
• the department develops a next-generation incident reporting policy and incident management system that significantly reduces the reporting burden for health workers while facilitating improved identification, follow-up and learning from serious patient safety incidents
• the department makes better use of routine data, registries and complaints data to facilitate and expedite identification and investigation of potential deficiencies in care
• the department streamlines its safety committees to improve information flows between hospitals, committees and the department, reduce duplication of functions, and ensure effective and improvement-focused follow-up of identified deficiencies in care
• the department invests in modern data management systems by expediting the development of a statewide patient identifier and the transition to electronic patient record systems in hospitals
• the Minister establishes a statutory Duty of Candour requiring any person harmed while receiving care to be informed and apologised to
• the department strengthens requirements for boards to report on harm, improvement plans and progress against them in annual quality reports
• the department works to improve voluntary reporting, including by monitoring hospital culture surveys to ensure that staff do not face barriers to reporting, discussing and addressing patient safety risks
• there be stronger obligations for clinical registries to report serious deficiencies in care once they are detected.
5. All hospitals should have access to independent clinical expertise to help identify deficiencies in care and focus attention on opportunities for improvement. To achieve this, we have recommended that:
• the department reinstates Limited Adverse Occurrence Screening so that all smaller hospitals have access to reliable and independent information on safety and quality performance
• all small hospitals develop ongoing partnerships with larger health services to ensure they receive adequate expert support for case audit and other clinical governance activities in all their major clinical streams
• larger health services consider initiating a cycle of regular external reviews of all their clinical units to maintain a focus on continuously improving performance
• all health services be required to recruit an independent expert to sit on their root cause analysis panel when investigating a sentinel event.
6. Risk should be managed across the system so that hospitals only offer care that is within their capabilities, with high-risk care concentrated in the centres where it is safest. To achieve this, we have recommended that:
• for all major areas of hospital clinical practice, the department develops and monitors compliance against capability frameworks delineating, for each hospital, which patients and treatments it has the capability to safely care for
• the clinical networks identify those procedures or treatments for which there is evidence of a material volume–outcome relationship, and the department acts to concentrate delivery of these public and private hospitals’ ‘minimum volume’ procedures and treatments within a designated set of ‘high-volume’ centres.
7. There must be robust assessment of clinical governance and hospital safety and quality performance in the department. To achieve this, we have recommended that:
• the department reduces reliance on hospital accreditation while working through national processes to evolve the accreditation process to a more rigorous one
• the department overhauls its performance assessment framework to ensure there is robust monitoring of safety and quality of care, incorporating risk assessment of hospital governance, as well as culture and patient outcomes
• the department pursues legislative change to make strong performance in safety and quality a standalone requirement of health services rather than something that can be traded off against performance under access and financial dimensions of performance
• the department establishes a formal panel of clinical reviewers who can be called on to undertake clinical reviews where indicated in the revised safety and quality monitoring framework.
8. Mental health services must be adequately funded to allow delivery of timely, safe and high-quality care. To achieve this, we have recommended that:
• the department ensures there is robust reporting and public discussion regarding indicators pertaining to safety, quality and pressure on mental health services
• the department develops a forensic mental health infrastructure sub-plan with a clear timeline to expand medium-security forensic bed capacity and to address other needs including those of adolescent and high-security patients.
9. Clinical leaders must be engaged to strengthen, direct and lead efforts to improve safety and quality of care. To achieve this, we have recommended that:
• the department establishes a Victorian Clinical Council to obtain the collective advice of clinicians on strategic issues
• the department rebuilds the clinical networks to lead safety and quality improvement work, with the network activities and priorities coordinated by the newly formed OSQI and each network accountable for improve statewide safety and quality outcomes on relevant dimensions of hospital care
• the department invests in system-wide clinical leadership by establishing, in partnership with Better Care Victoria, a clinician leadership training strategy that incorporates training in contemporary quality improvement methods for all leaders of significant clinical departments
• the clinical networks work to reduce clinical practice variation in all hospitals, including by developing or sharing best practice protocols for common use
• the CEO of OSQI should have authority to issue best-practice guidelines and protocols on the advice of the clinical networks and the clinical council, and clinicians should be held accountable locally for their appropriate application.
10. The system must have a stronger focus on improving patients’ experience of care. To achieve this, we have recommended that:
• the department holds hospitals accountable for managing care transitions, providing professional interpreter services when required and monitoring progress against goals set by the hospital for continuous improvement of the patient experience
• the department works with the Health Services Commissioner to identify hospitals that are underperforming on dimensions of patient experience including management of complaints
• the OSQI adopts improvement of patient engagement and patient experience as a priority improvement goal for the hospital system.
