1. Preamble

Quality - 'the extent to which a service or product produces a desired outcome or outcomes'.

The purpose of this Position Statement is to:

• clearly articulate the AMA view on the determinants of quality and safety in public hospitals
• establish the AMA's presence in the quality and safety debate
• position the AMA on the front foot in public discussion, particularly in view of the 2007 federal election campaign
• consolidate and further establish the AMA position of task delegation

Australia has a high quality health system. Our health system provides more than 230 million medical services each year to Australians at a cost of $12 billion. In addition we provide 7 million total hospital admissions, 4.2 million of which are in the public hospital system provided at no charge to the patient. The vast bulk of medical training occurs in the public hospitals turning medical students into fully trained and fully fledged medical practitioners ready to practice independently.

Public comment on many issues in health is overwhelmingly negative. This creates in the public mind a perception of a low quality health system riddled with adverse events and near misses where litigation is the only form of redress available to patients. The Australian health system delivers a large number of low cost, high quality medical and health services. This message needs to be reinforced in the community not least because a health system constantly under unjustified attack will lead to more defensive medicine which comes at a cost.

Over the last 30 years, we have seen a substantial fall in perioperative death rates through improved anaesthesia management, a substantial decline in death rates from heart attack and stroke, declining death rates from many cancers, improved diabetes management, improved options for mental health care, lower perinatal and maternal death rates and longer life expectancy etc (refer AIHW Australia's Health 2006, Chapter 2, pgs 15 to 129).

This has not come about because of the Australian Hospital Care Study or quality assurance activities at the hospital or even as a result of ACHS accreditation or ACSQHC activities. These matters all impact at the margin. There is a lack of recognition in the Australian community of the contributions to quality, safety and improved health outcomes from a highly trained health workforce supported by good research as opposed to the smaller contribution from formal quality measurement and assurance activities.

The improvements, we suggest, come about because large numbers of highly trained and motivated people have put their mind to the task over a long period of time putting forward ideas, testing the ideas with peers, gathering the best ideas from colleagues around the world, being well trained and training those following. This has enabled the profession to develop better methods of managing patients to produce better outcomes. It enables the profession to work with new technologies and new pharmaceuticals and improved processes for health care delivery in providing better care for patients.

The vast bulk of improvements in the quality and safety of health care over the long term arises from an adequately resourced, highly trained, and fully credentialed health and medical workforce. These components are critical for the delivery of a high standard of health care to patients. For high standards of quality and safety to be assured, the AMA believes it is essential there is strong clinical involvement in and ownership of processes set up to measure and assure safety and quality across the system.

Public hospitals continue to operate under great pressure and this Position Statement acknowledges that resource and capacity restraints have a significant impact on quality and safety and addresses the lack of reliable mechanisms for routine data collection and dissemination. Strategies for developing quality and safety standards can only be derived from robust data sets. It is a common situation throughout the public hospital system that data is collected without input from those directly involved in providing patient care. This immediately compromises its ability to bring about improved patient outcomes.

The profession is currently challenged by workforce shortages which have highlighted the need to embrace and characterise the concept of task delegation to ensure the medical practitioner has clinical responsibility for patient treatment. The concept of task delegation has highlighted the need for clinical cooperation between medical practitioners, and the allied health and nursing sectors. The medical profession is reliant on these other highly trained health professionals to deliver modern care in a team environment.

2. Key Issues

There has been an enormous amount of work done over the last decade on efforts to standardise safety and quality systems that improve patient outcomes. Traditionally these have involved the development and implementation of centralised processes that are ultimately based on flawed data and rely on a culture of blame that is counterproductive as fear of retribution may discourage health care workers from disclosing involvement in an adverse event.

The AMA believes driving the quality and safety agenda from the local level improves the scope for 'buy in' from the workforce which translates to clinical ownership and greater commitment to improving and observing quality and safety assurance processes and quality measurement. Ownership involves the identification of what can and can't be changed.

One key indicator of the pressure all around the country on the public hospitals is the bed occupancy rate. Following are some of the stand-outs in 2004-05:

• NSW reports an average public hospital acute bed occupancy rate of just over 90%¹.
• In Victoria, the overall average bed occupancy rate is 98.6%².
• In the ACT, it was 92.4%²; and
• In the NT, it was over 100%².

Average bed occupancy rates mask particular sites where occupancy rates are extremely high, with serious implications for quality and safety. The available evidence suggests that major metropolitan teaching hospitals tend to have above average rates, while country hospitals are more likely to run below the average. The newly amalgamated Sydney South West Area Health Service reports an overall bed occupancy rate of 94.1% with several major facilities on the wrong side of that average (RPA, Concord, Bankstown and Liverpool).³

There is substantial Australian and international evidence that high average bed occupancy rates are not consistent with the efficient operation of public hospitals or with quality outcomes. If average bed occupancy rates are sustained above 85% of technical capacity (the NHS uses a band of 82 to 85%), the impact is felt. One World Health Organisation paper expresses the proposition in the following terms:

"Indeed, we can be fairly confident in making a clear and categorical statement about bed occupancy. In acute hospitals, on optimal average bed occupancy rate lies in the region of 85%; rates much below 80% are clearly inefficient, while average rates of 90% give rise to an increasing probability that, on any given day, the hospital in question may have insufficient beds available to meet random daily fluctuation in demand for care."⁴

Attempts to maintain very high rates of activity, with correspondingly high average bed occupancy rates, for extended periods put lives at unacceptable risk, create overcrowding, access block, and ultimately system failure. The scientific evidence is not limited to the risk that sick people may not be able to get access to hospital when they need it. There are studies which show clear links between high bed occupancy rates and inferior infection control outcomes.⁵

There is clear evidence emerging that greater clinical involvement in the management in the design of systems to handle emergency admissions in a way which avoids access block can have positive effects on overall length of stay of emergency patients and can be associated with improved morbidity and mortality for patients.

Pressures at a particular facility may be less serious when another has capacity to share the load. However, we are witnessing an increasing tendency for State and Territory administrations to run the entire system at "full throttle" for extended periods. As a result, emergency cases have been transported hundreds of kilometres to gain admission.

Some of the reasons for overcrowding and access block include insufficient funding, a reduction in the physical infrastructure (the number of acute in-patient beds), a failure to adequately grow aged care sector beds and staff shortages which mean that otherwise operational beds cannot be used.

Opportunities to reduce overcrowding and minimise access block can be realised by developing emergency management units, rapid access teams, alternate pathways and timely and appropriate access to transitional care beds and aged care facilities. Establishing and maintaining such mechanisms will go a long way to reducing the potential for the occurrence of adverse incidents.

Dispassionate measurement of health outcomes is a necessary precondition to improving quality and safety. We need to make sure that the outcome of care assessment and measurement is integrated into the delivery of care and ensure the process is not an additional onerous burden on clinicians. Properly designed and conducted health outcome studies provide the strongest evidence of change to the quality of care available, much more than can be achieved by focussing on the avoidance of adverse events necessary as that is for confidence in the system to remain.

3. Prerequisites for good clinical outcomes

3.1 A highly trained medical workforce is essential to safety and quality in public hospitals. The AMA strongly supports the training of medical students, Interns and PGY2 doctors in public hospitals even though workforce shortages and a shift in work to the private sector have reduced the training capacity of the public sector in recent years.

3.2 A fully credentialed medical staff ensures a competent workforce. The AMA supports the implementation of a standard method of credentialing, the AMA remains opposed to credentialing being linked in any way to national registration.

3.3 Adequate numbers of trained health professionals is critical to maintaining and improving safety and quality standards. The AMA supports the concept of team based care under the leadership of an experienced, highly skilled medical practitioner

3.4 Adequate physical infrastructure, including acute beds, to meet the needs of the population and capacity building in recognition of the increase in needs that attend an ageing population. The level of recurrent capital and equipment expenditure must ensure the best medical equipment is available for patient care and an appropriate training environment.

3.5 The AMA believes average annual bed occupancy rates should not exceed 85% to give the public hospital system and the people working in it the time needed to deliver optimum outcomes and benefits to patients.

3.6 Adequate mental health and transitional care beds are essential to safety and quality.

3.7 Rapid access to diagnostic radiology and pathology by hospital doctors and GPs will improve patient safety and optimise timely health care delivery.

3.8 Communication with GPs on admission and discharge. Discharge summaries electronically generated at time of discharge are mandatory for good continuum of care and good clinical outcomes.

4. Prerequisite systems for improving quality and safety

4.1 Robust, long term data collection and analysis systems to assess the quality of current practice and suggest further improvements.

4.2 Integrated IT systems have the capacity and scope to deliver superior safety mechanisms. It is important that staff members are adequately and appropriately trained to use the systems properly to ensure the benefits are realised.

4.3 IT systems should have the capability to interface with GP surgeries subject to patient privacy and system security considerations.

4.4 Safe medication management systems that deliver accountability in all aspects of patient care are a particularly important aspect of safety and a well implemented program will reflect positively in patient confidence and improved staff morale.

4.5 A formal, reliable complaints mechanism is needed for staff that allows for rapid response and resolution. Such a system, well implemented would contribute greatly to staff morale and sense of value to the organisation.

4.6 Risk management programs are fast becoming an integral component of hospital procedure. The AMA supports appropriately constructed, relevant programs that are not weighed down by burdensome administrative processes.

4.7 The AMA supports the development and implementation of measures of quality delivery of healthcare that distinguish between known and expected complications and preventable adverse events.

4.8 The AMA continues to fully support peer review models of professional regulation.

4.9 Clinical governance and medical leadership with clinically practicing doctors having a greater role in clinical and hospital management are essential.

5. Quality Assurance Activities

The AMA supports stronger clinical ownership of quality assurance measures that contribute to improved patient outcomes. Establishment of a mechanism that enables clinicians to get together regularly, armed with good quality information, to look at and improve best practice is essential. Some good models exist in the private sector, for example the Centralised Management Data Service (CDMS).

Doctors need to feel confident that reporting an adverse event will lead to reviewing and improving the system processes that caused the error rather than an emphasis on blame and litigation.

The AMA supports root cause analysis as a means of assessing and improving quality and safety in a non-threatening way. The findings of such analysis need to percolate through the whole hospital system in each State and Territory and not be confined to a single institution.

6. Quality assurance activities supported by the AMA include:

6.1 Peer reviewed clinical audits - finding the time to conduct an audit remains a major barrier for clinicians. These should be contemporaneous between completion and collection.

6.2 Clinical risk management - local ownership improves commitment and increases involvement

6.3 Clinical indicators - should be easily obtainable, clinically relevant and supported by resources for accurate and complete collection

6.4 Clinical coding of outcomes - there are serious problems with the accuracy of clinical coding at present

6.5 Critical incident reporting to local management for analysis and action to correct deficiencies

6.6 Root cause analysis

6.7 Peer review models of professional regulation

6.8 Medication managementaudits

6.9 85% average bed occupancy - access block reduced, rapid access teams, alternate pathways, emergency management units. There should be broad based, de-identified clinical reporting of bed occupancy against average.

It is important for clinicians to work in close liaison with hospital administrators to review and develop improved techniques for measuring quality. Time constraints are often cited as a major reason for neglect of quality assurance. Quarantining of time is necessary to enable discussion and the review of processes. This is an option not seriously considered in many hospitals and it is rarely supported with adequate resources to enable performance to the highest standards.

It is important for clinicians to be assessed by peers as competent to perform within a clinical scope and national credentialing criteria are an important aspect of quality assurance. Credentialing criteria should be formalised at a local level.

Quality and safety standards and assessments should be driven at the local level giving ownership to staff who can then get direct feedback on their endeavours to improve safety, quality and health outcomes. Local ownership means there is an increased likelihood appropriate recommendations will result in systems that deliver improved patient outcomes.

References:

1. NSW Health Annual Report 2004-05.

2. Derived from AIHW Hospital Statistics 2004-05.

3. Year in Review, 2004-05, SSWAHS.

4. Financing Health Systems Through Efficiency Gains, Martin Hensher, working paper for CMH (WHO), May 2001

5. See, for example, Bed occupancy, turnover intervals and MSRA rates in English hospitals, Cunningham JB Kernohan WG Rush T, British Journal of Nursing 2006, 15 (12):656-60.