7th Health Services and Policy Research Conference

““You wouldn’t be dead for quids!”You wouldn’t be dead for quids!”

5 December 20115 December 2011

Chris BaggoleyChris Baggoley

Aged Care shortage chokes hospitals

Source: The Age, Thursdasy June 2, 2011

HEALTH REFORM - Overview

Better coordinated and localised delivery of health services

Changed responsibilities between Commonwealth and State Governments

More Sustainable Financing

New National Institutions

Greater Transparency and accountability

BENEFITS OF NATIONAL HEALTH REFORM

An integrated and high performing health system

Easier for patients to move around the health system and receive the care they need, when and where they need it

A focus on prevention and primary health care will keep people well and out of hospital

Increased transparency on the performance of health services at a local level

IMPROVED ACCESS TO HOSPITALS

National Emergency Access Target 90% of all ED patients across all triage categories will be admitted, referred or discharged from Emergency

Departments within four hours

Elective Surgery Target Patients to be treated within clinically recommended time will be raised from 95% to 100% by 2015

Implementation timeframe will be extended in smaller states by one year to 2016

MAJOR EMPHASIS ON PERFORMANCE AND

ACCOUNTABILITY

New Performance and Accountability Framework

National Health Performance Authority (NHPA)

Hospital Performance Reports and Health Communities Reports

Emergency doctor:

We can't cope !

Hospital ‘overcrowded, overwhelmed’

The Age – 6 October 2011

Wait at hospitals is a test of patients

Source: Herald Sun, Thursday June 2, 2011

Literature Review

“The priority is not simply devising yet more standards and indicators, but

working on the nuts and bolts of how we turn measurement for improvement into

tangible change in practice”

Source: Scott, I & Phelps G

“Measurement for Improvement:

Getting one to follow the other” IMJ 2009, 39, 347-351

Literature Review

“The available evidence suggests that targets face resistance at local level if they are imposed

on those who must implement them. Mechanisms that foster participation and a sense

of ownership are an important element of a target based strategy”

Source: Ernst, K., Wismar, M et al Chapter 4

“Improving the Effectiveness of Health Targets”

In “Health Targets in Europe: Learning from Experience”,

European Observatory on Health Systems and Policies, Observational Studies Series No 13, 2008

Literature Review

“A target should be sufficiently challenging to stimulate new and

better ways of doing things rather than simply waiting for nature to take its

course”

Source: McKee, M Chapter 3: On Target?

Monitoring and Evaluation in

“Health targets in Europe: Learning from

Experience” European Observatory on Health Systems and Policies 2008, Observations Studies Series No 13

Literature Review

“The most difficult phase of redesign is not identifying issues or designing new

solutions; it is implementing those solutions and embedding the redesigned

model into core business processes”

Source: O'Connell, T, Ben-Tovim, D., McCaughan B, and McGrath, K

“Health services under siege: the case for clinical

process redesign” MJC 2008, 188, S9-S13

Literature Review

86 cases of hospital process redesign

that have not led to consistent

improvements in either patient

outcomes or system performance

Scott, I, Wills, R-A et al “Impact of hospital-wide

Process redesign on clinical outcomes: a comparative study of

internally versus externally led intervention” BMJ 2 & Q: 2011: 20: 539 - 548

LITERATURE REVIEW

Risks of performance targets

“Hitting the target but missing the point”, ie quantity not quality

Alienation of key stakeholders where there is a lack of consultation, planning and communication

“Gaming” including cherry picking of patients and manipulating data

Source: Expert Panel Review of Elective and Emergency Access

Targets under the National Partnership Agreement in Improving

Public Hospital Services: Supplementary Annexure. Report to COAG: August 2011 pp 15-16

Literature Review

Emergency Department Targets

Strong evidence linking ED overcrowding and access block to poorer patient outcomes in Australia

Similar association in Canada, USA and UK

ED overcrowding and access block contribute to

20 - 30% excess mortality rate

Also contribute to prolonged inpatient length of stay

Source: Expert Panel Review of Elective and Emergency AccessTargets under the National Partnership Agreement in Improving

Public Hospital Services: Supplementary Annexure. Report to COAG: August 2011 pp 17-18

Literature Review

Elective Surgery Targets

Problems with Patient categorisation

Variation in use of urgency categories across surgical specialties and between hospitals

Variation according to socio-economic status of patient and remoteness from health services

Source: Expert Panel Review of Elective and Emergency AccessTargets under the National Partnership Agreement in Improving

Public Hospital Services: Supplementary Annexure. Report to COAG: August 2011 p.23

Access Block and the Introduction of

The Four Hour Rule Program in 4 Western Australia Hospitals

Monthly performance against the Four Hour Rule Program in

Western Australia **July 2008 – April 2011

Elective Surgery Urgency Categories

Cat 1 Admission within 30 days desirable for a condition that has the potential to deteriorate quickly, to the point

that it may become an emergency

Cat 2 Admission within 90 days desirable for a condition causing some pain, dysfunction or disability,

but which is not likely to deteriorate quickly or become an emergency

Cat 3 Admission within 365 days for a condition causing minimal or no pain, dysfunction or disability,

which is unlikely to deteriorate quickly and which does not have the potential to become an emergency

Source: Expert Panel Review of Elective and Emergency AccessTargets under the National Partnership Agreement in Improving

Public Hospital Services: Supplementary Annexure. Report to COAG: August 2011 p. 56

Clinical PriorityCategory: NSW

Cat 1 Admission within 30 days desirable for a condition that has the

potential to deteriorate quickly to the point that it may become

an emergency

Cat 2 Admission within 90 days desirable for a condition which is not

likely to deteriorate quickly or become an emergency

Cat 3 Admission within 365 days acceptable for a condition which is

unlikely to deteriorate quickly and which has little potential

to become an emergency

Cat 4 Patients who are either clinically not ready for

admission (staged) and those who have deferred admission for

personal reasons (deferred) (Not Ready for Care)

Source: Expert Panel Review of Elective and Emergency AccessTargets under the National Partnership Agreement in Improving

Public Hospital Services: Supplementary Annexure. Report to COAG: August 2011 p. 57

NSW

VIC

QLD

WA

SA

TAS

ACT

NT

Cat 1

26%

27%

37%

28%

32%

39%

30%

42%

Cat 2

30%

48%

45%

36%

35%

41%

50%

39%

Cat 3

43%

26%

18%

36%

34%

20%

20%

18%

Percentage of patients byUrgency category (2009-10)

Source: Expert Panel Review of Elective and Emergency AccessTargets under the National Partnership Agreement in Improving

Public Hospital Services: Supplementary Annexure. Report to COAG: August 2011 p. 56

Guiding Principles

1. Targets and the changes required to meet them will require commitment right across the health and hospital system

2. Hospital executives will need to work in partnership with clinicians to achieve sustainable change

3. Clinical engagement and clinical leadership will be essential if the targets are to be met

4. Targets must drive clinical redesign with a whole-of-hospital approach

5. Clinical redesign must ensure patient safety and enhance quality of care

Source: Expert Panel Review of Elective and Emergency AccessTargets under the National Partnership Agreement in Improving

Public Hospital Services: Supplementary Annexure. Report to COAG: August 2011 p.13

Guiding Principles

6. Definitions to be clear and consistent across all jurisdictions

7. The performance of jurisdictions is not comparable

8. Progress towards the targets needs to be linked with continual monitoring of safety and quality performance indicators and audit

9. The impact of targets on demand needs to be monitored and early strategies developed to ensure achievements are

sustainable

10. Quality of training is maintained

Source: Expert Panel Review of Elective and Emergency AccessTargets under the National Partnership Agreement in Improving

Public Hospital Services: Supplementary Annexure. Report to COAG: August 2011 pp 14-15

A Consumer ViewA Consumer Viewof Health Careof Health Care

“I have a right to safe and high quality care”

This means: To be free of being infected by my hospital or health

worker To be given the right medications at the right time To be assessed for the risk of VTE To undergo the correct procedure, operation, test, x-ray To be rescued if my condition unexpectedly deteriorates

Australian Safety and Quality Goals for Health Care

•Potential areas for Goals– Healthcare Associated Infections– Medication Safety– Partnering with patients and consumers– Appropriateness of care

- Cardiovascular Disease (Stroke care and Acute Coronary

Syndrome) - Diabetes

Standard 7Blood and Blood

Products

Standard 10Preventing Falls and

Harm from Falls

The NSQHS Standards

Standard 1Governance for Safety and

Quality in Health Service Organisations

Standard 2Partnering withConsumers

Standard 4Medication Safety

Standard 3Healthcare AssociatedInfections

Standard 8Preventing and

Managing Pressure Injuries

Standard 9Recognising and

Responding to ClinicalDeterioration in Acute

Health Care

Standard 5Patient Identificationand ProcedureMatching

Standard 6ClinicalHandover

National Safety And QualityStandards

Identify issuesand risks

Health Sector Programs

Data andinformation

Accreditation – Measurement

of systems,actions and data

Solutions, actionstools and supports

ACSQHC: The Australian Quality Improvement Cycle

• Antimicrobial Resistance

Time Line of the Rapid Rate of Resistance

Source: Gottlieb T. Nimmo G. Med J Austr 2011. 194:281-3

Development of a National AMS Program

Activities will include:

Undertaking a formal gap analysis to identify deficits or areas to be prioritised in the national program.

Consultation with jurisdictions, clinicians, private sector, and primary care providers to develop a national plan with key stakeholders including: Evaluation of existing resources available. Monitoring national and international evidence regarding AMS Developing mechanisms for implementation of AMS nationally that allows for harmonisation of the key factors and local implementation such as on-line workshops based on the formal gap analysis

Steering Committee

Chair – Chief Medical Officer

Members – Chief Execs

ACSQHC Prevention Programs

• Hand Hygiene

• Hospital AMS

• Infection control guidelines

• Clinical capacity

• National Surveillance

NHMRC1. Infection control

guidelines2. AMR Advisory

Committee- Community acquired• MRSA• Beta lactamases• E coli- Research priorities

PBAC/TGA•Pharmaceutical Benefits Advisory Committee

•Regulation

NPS Campaigns

• Community prescribers

• Mass audience

Animal

Agriculture

The role of this plan would include:• implementing a comprehensive national resistance monitoring and audit system• coordinating education and stewardship programs• implementing infection prevention and control guidelines• expanding funding to support research into all aspects of antibiotic resistance• reviewing and upgrading the current regulatory system applying to antibiotics• undertaking community and consumer campaigns

Food authorityProfessional

organisations

Australian AMR Plan

Choice of Choice of antibioticantibiotic

Infection control

Accreditation Data

Programs

Antimicrobial ResistanceQuality Improvement cycle

Accreditation

DoHA S & T NHPA

NAUSP

Surveillance

AGAR DUSC

NAUSP PHLN BEACH

NPS

ACSQHC

Agencies

AICA

NHMRC

Research

Translation

NPS AMSTGA

PBACTGx

ACSQHC

TGx Uni, Colleges

NHMRC ACSQHC

NPS