Kupu Taurangi Hauora o Aotearoa

1. Kupu Taurangi Hauora o Aotearoa

2. Health Quality and Safety Indicators All the data, all the commentary All in one place

4. Placeholder: measure of adverse events An overarching measure of adverse events across the health sector will be used to summarise safety (this could be a measure of harm-free care).

5. Falls Falls in health care have been identified as the most commonly reported type of harm in the annual serious and sentinel events report. Each year around half of all events with serious harm are falls and around half of these lead to a fractured neck of femur On average, two patients fell and broke their hip in New Zealand’s hospitals every week in 2012. This typically added an estimated month to their hospital stay, and cost a minimum of $2.6 million. This level of two incidents a week has been consistent for the last two and a half years.

6. Run chart showing in hospital falls leading to a fractured neck of femur by month, 2010-2012

7. Commentary • We have settled on fractured neck of femur following a fall in hospital as a reasonable compromise between an event of uneqivocal harm and cause and one with reasonable numbers. These represent around a quarter of all serious and sentinel events reported in the annual SSE report, so are a substantial proportion of recorded harm. • The number of falls has remained fairly consistent over the last two and a half years. • We estimate that the average increase in length of stay associated with falling in hospital and fracturing neck of femur is over month.

8. Central line associated bacteremias and Healthcare associated S.Aureus bacteremia Preventing healthcare associated infections is a part of the Commission's patient safety campaign, including ensuring good hand hygiene and preventing central line associated bacteraemia (CLAB) in intensive care units. Central line associated bacteremias in ICUs have been a long standing issue in healthcare and have often been considered an inevitability. Recent evidence shows however that the introduction of a small and low cost bundle of interventions can virtually eliminate these. New Zealand established a collaborative (Target CLAB Zero) working between DHBs to attempt to do this. S. Aureus bacteremia is the most common healthcare associated infection in New Zealand hospitals, and can be associated with increased time in hospital, disablement and even death. Good hand hygiene is one way of reducing the risk of this infection

10. Commentary • Measurement of harm in the field of infection control has, not unreasonably, concentrated on reduction of infections. There is less history of measurement of harm (for example in increased mortality) or cost (although estimations such as those of Graves et al 2003 and Cummings et al 2010 exist). • In particular, original research in the effects of hand hygiene programmes have tended to concentrate on Staph. aureus infection rates ( Kirkland et al 2012, Roberts et al 2012) or Methicillin-resistant Staph. Aureus infection rates (Grayson et al 2008, ). These papers tend to demonstrate that improvements in hand hygiene are associated with a reduction in infection rates, making clear the intervention logic and appropriateness of linking together these measures as related process and outcome markers. • Hand Hygiene NZ adopted healthcare associated Staphylococcus aureus bacteraemia per 1000 patient days as its outcome measure,. Since Staphylococcus aureus is the most common healthcare associated pathogen in most New Zealand hospitals we believe this to be the best easily available measure. • Data collected by HHNZ appears to show a recent downward trend in S. Aureus rates

11. Run chart showing CLAB per 1000 line days by month, 2011-2013

12. Commentary • Following the implementation of the Target CLAB Zero CLABs appear to have been almost eliminated in New Zealand Intensive Care Unit. From what was considered a conservative estimate of 3.3 CLABs per 1000 days in 2011, there are now considerably fewer than 1 per 1,000 line days. • Put another way, in the 12 months since April 2012 there have been 15 CLABs recorded in New Zealand ICU had CLABs continued to occur at the pre-existing rate there would have been around 100.

13. Perioperative harm • There are potentially many harms associated with operations that could be included in this analysis. We have chosen to include two which are relatively numerous and unequivocal and potentially serious : Deep Vein Thrombosis/Pulmonary Embolism, and Postoperative Sepsis • This measure will align with the quality and safety marker for perioperative harm. • For comparative purposes we have included data from OECD/Commonwealth Fund in 'Related information'. We anticipate more recent data becoming available soon.

14. Post operative complications per 1000 at risk admissions 2005-12

15. Commentary • This measure is essentially the same as that used in the Quality and Safety markers, but to ensure that the measure can be meaningfully compared over time it is turned into a rate against admissions. The use of the “at risk” admissions is to denote that certain cases, where there is no real risk of the complication, are excluded from the calculation of the rate. Fuller details of the construction of these indicators is available at the HQMNZ website. • Postoperative DVT/PE appears to have been largely stable over this period, but post operative sepsis is increasing, the reasons for this are unclear.

16. Postoperative sepsis per 100,000 hospital discharges, 2009 Note: Age-sex-SDX standardized rates. * 2008. ** 2007. *** 2010. THE COMMONWEALTH FUND Source: OECD Health Care Data 2012.

17. Commentary New Zealand and Australia appear to stand out as having high postoperative sepsis rates based on this international comparison. The Commission's programme of work covers the introduction of the surgical checklist which is associated with reduction in postoperative complications. The separate issue of surgical site infection will be the subject of future work programmes.

18. Foreign object left in body during procedure per 100,000 hospital discharges, 2009 Note: Age-sex-SDX standardized rates. THE COMMONWEALTH FUND * 2008. ** 2010. Source: OECD Health Care Data 2012.

19. Commentary • New Zealand is towards the higher end of the range of foreign bodies retained following an operation. It is worth noting that this is a very rare occurrence: fewer than ten such cases are usually recorded each year in the Commission's annual serious and sentinel events report. This means that one or two fewer or more incidents (the sort of change that reflects nothing other than ‘random variation’) can change the relative position on this graph substantially. • Nevertheless, this is considered a ‘never event’ - something that should never happen - in most countries, and as such is worth reflecting upon.

20. Under development: medication Ensuring safe medication management is part of the Commission's patient safety campaign. This measure will align with the quality and safety marker for medication management.

21. Placeholder: pressure injury Measures of pressure injury are being developed through the Office of the Chief Nurse. Once routinely available we intend to include these here.

22. Placeholder: patient experience This is a vital but complex area. There is no currently available nationally consistent data source for a measure to adequately address this area. There are several options that we are considering for this section which include: informed consent measure, patient experience survey, mental health KPI, patient satisfaction survey. This is so important that we intend to get this right first time with work planned for early 2013.

23. Cancellations of elective surgery by hospital after admission This indicator measures the percentage of elective surgery (excluding maternity surgery) cancelled by the hospital after the patient had been admitted. The results provide insights into how close the system is running to capacity and a measure of patient experience. This indicator includes patients who were rebooked and admitted at a later date.

24. Percentage of operations cancelled after admission by month, 2008-2011

25. Percentage of operations cancelled after admission by year, 2008-2011

26. Around 1 percent of operations were cancelled after admission. This proportion has been relatively consistent across the country over the past four years. While this appears to be a small percentage of total operations, it amounts to some 5,000 cancellations per year and represents a significant level of resource and considerable disruption to patients. There is considerable regional variation, with a nine-fold difference between the highest four-year average level of cancellations (2.7 percent) and the lowest (0.3 percent). The analysis above does not take into account the reasons for cancellation. It is reasonable to suspect that there may be a seasonal impact on this indicator, with medical acute conditions likely to dominate during winter meaning that fewer beds are available for elective surgical cases, increasing the cancellation rate. However, our monthly view shows little evidence of this

27. Deaths potentially avoidable through health care (amenable mortality) This indicator is well-tested and accepted as a whole-of-system health outcome indicator. It shows the extent to which available treatments are applied to diagnosed conditions and shows the potential for gain in health outcomes. As an internationally calculated indicator, it should, in theory, allow international comparisons, although time spent collating consistent data sets slows down calculation (the most recent data available relates to 2006–07).

28. Age-standardised amenable mortality rates by year, 1997-2006

29. Commentary • New Zealand's rate of amenable mortality has fallen notably over the last 10 years. This fall mirrors the pattern seen in most high-income countries. During this period New Zealand has had one of the higher mortality rates internationally, although it is not a particular outlier. For example, the amenable mortality rate here remained around 30-40 percent higher than in Australia between 1997 and 2007, even as the rate fell. • While amenable mortality is probably the best measure that we have to consider the effect of healthcare on mortality (other measures such as life expectancy are influenced by much broader causes such as poverty, inequality, and social infrastructure as well as quality of healthcare) it does have some weaknesses. It is dependent upon similar recording of details about patients in different countries which cannot necessarily be guaranteed (although similar recording systems are used, local practice in their interpretation can vary). The precision and complexity of calculating the measure together with the need to get nationally consistent data sets makes this quite an 'out of date' indicator, the most recent data available to us relates to 2006-07. • So we include a complementary measure, potential years of life lost alongside the amenable mortality measure. This looks at deaths under the age of 70 and calculates the total years of life lost through premature death. These data are available from the OECD up to 2010. Again New Zealand has a relative high number of years of life lost, consistent with its relatively high amenable mortality rate.

30. Countries age-standardised amenable mortality rates for under 75 years

31. NZ and Australian age-standardised amenable mortality rates by year, 1997-2006 The continued difference between New Zealand and Australia is noteworthy. However, care should be taken in the interpretation of these data. Tobias et al, http://www.health.govt.nz/publication/saving-lives-amenable-mortality-new-zealand-1996-2006, note that assuming that the higher amenable mortality rate in New Zealand points to a less effective health system is flawed, "Once corrected for differences in non-amenable mortality (as a proxy for these underlying ‘structural’ factors), no difference in amenable mortality remains (or a slight New Zealand advantage is seen in recent years), suggesting that the two health systems are in fact performing at a similar level of effectiveness."

32. Potential years of life lost, men, OECD countries, 2010 (or nearest available year)

33. Potential years of life lost, women, OECD countries, 2010 (or nearest available year)

34. Placeholder: functional outcomes Functional health outcomes scores are being considered for this area.

35. Occupied bed-days for older people admitted two or more times as an acute admission per year This indicator is a useful proxy for the effectiveness of the integration of primary, acute and long-stay care. It illustrates effectiveness at avoiding unnecessary admissions and ‘stepping down’ to less intensive forms of care. For ease of international comparison, 'older people' is defined as all those aged 75 and over. We received very helpful feedback that a more useful indicator for New Zealand would also include Maori and Pacific peoples aged 55 and over. This is included in the 'Related information' section.

36. Occupied bed-days associated with 75s and over admitted twice or more as an emergency per 1,000 population

37. Commentary • Good integration of care services is an increasing priority for health systems in the developed world, and an area of particular concern for ageing populations. Poorly integrated care results in older people ‘falling down the gaps’ until the most urgent, intensive and expensive care – an acute admission to hospital – is required. A low number of occupied bed-days per capita and low regional variation are desirable. • Compared with the UK (the other country where there is a consistent time series for this indicator), New Zealand has around a 40 percent lower level of bed occupancy and considerably less regional variation. The variation that exists prompts the question, could this rate be improved further through widespread adoption of the integration practices seen in areas with the lowest rates? • This indicator relates to ambulatory sensitive hospitalisations, a series of measures that the Commission will explore in the 2013 Atlas of Healthcare Variation.

38. Related information

39. Occupied bed-days associated with older people admitted twice or more as an emergency

40. This variant of the measure includes Maori and Pacific peoples aged 55-74. When tested during our consultation process, respondents considered this measure more appropriate for New Zealand.

41. Occupied bed-days associated with 75s and over admitted twice or more as an emergency in New Zealand and England

42. Comparison with England demonstrates that New Zealand has notably low levels of bed occupancy associated with older people returning to hospital as an acute admission. This is suggestive of relatively successful integration of primary, hospital and aged care.

43. Occupied bed-days associated with people aged 75+ admitted twice or more as an emergency, per 1,000 population, by ethnic group

44. Absolute comparisons between different ethnic groups are complicated for this measure as the age distributions are so different (a much greater proportion of the total 'other' - primarily NZ European - population is aged 75+) so we present 75+ and 55+ for each ethnic group. These show, however, higher occupied bed days associated with Maori and especially Pacific peoples populations, regardless of which age group is considered.

45. Planned day case turns into unplanned overnight stay This indicator captures inconvenience to patients and disruption to planned hospital flow. The data may reflect an adverse incident in a procedure, unrealistic expectations about which patients are suitable for day-case surgery or some local factor. The indicator operates as a prompt for further enquiry and a measurement of quality and efficiency.

46. % day cases become overnight stays

47. Nationally, the proportion of day cases that turn into unplanned overnight stays has remained consistent over the last three years. Nevertheless, on the face of it, this figure equates to up to 10,000 people a year who expected to be in and out of hospital in a day who had to make an overnight stay. • This measure does not identify the reasons for an overstay and there may be a very legitimate clinical reasons for keeping patients overnight. Hence, the results need to be interpreted with caution. To help with this we show the change in national intended day case rate in the next pane. Whilst there are some caveats to this measure (we have excluded two DHBs from this calculation as their recording of day cases is inconsistent compared to the rest of the country), there is no obvious relationship between day case rate and day case overstay rate. In other words the places with the highest day case rates are not those with the most overstays. • We would anticipate variation in results between DHBs in relation to demographic or geographic factors (for example, in rural settings a potentially longer distance to hospital may affect ability to travel within the same day).

48. Related information

49. % day cases become overnight stays and % day cases

50. While day cases as a proportion of no-acute hospital events have increased slightly since 2008, the level of day case overstay has remained stable.