Towards national indicators of safety and quality in health care

1. Towards national indicators of safety and quality in health care Jenny Hargreaves Economics and Health Services Group Australian Institute of Health and Welfare

2. The National Indicators Project Being undertaken by the Australian Institute of Health and Welfare for the Australian Commission on Safety and Quality in Health Care Funded by the Commission Objectives: Recommend indicators for national reporting on safety and quality Enable the Commission to report publicly on the state of health care safety and quality Enable the Commission to advise Ministers on whether existing reporting processes and collections should be continued, enhanced or replaced

3. The Australian Institute of Health and Welfare Australia's national agency for health and welfare statistics and information An independent statutory authority operating under the Australian Institute of Health and Welfare Act 1987 Ensures data collections are kept securely and confidentially Sets our role to develop, collate, analyse and disseminate information and statistics Board, Ethics Committee Work closely with State, Territory and Australian Government agencies, and other stakeholders 100+ reports each year: www.aihw.gov.au

4. The National Indicators Project In collaboration with the Commission With advice of the Project�s National Indicators Advisory Group An AIHW discussion paper Towards national indicators of safety and quality in health care recently released A draft suite of 58 indicators Context information on indicator purpose and development Consultation phase currently in progress Final report to the Commission in early 2009

5. Scope of health services covered Settings in which clinical care is delivered by registered practitioners where the primary purpose of the setting is health care Health care provided to patients Hospitals, general practice, non-acute care, community health�. Includes dental health care, ambulance and residential aged care Excludes public health, such as health promotion, environmental health, safety promotion activities, OHS

6. Definitions: Safety and quality Safety � avoidance or reduction of actual or potential harm from health care Quality � 4 dimensions Appropriateness � based on established standards Effectiveness � achieves desired outcomes Continuity of care � coordinated across providers, time Responsiveness � respect for persons, client oriented: patient-centredness A �balanced scorecard� approach, in part

7. Exclusions Access Focussing on the safety and quality of care that is delivered, rather than on whether patients receive care, or how long they wait Currently included in other national indicator sets, eg National Health Performance Committee indicators in AIHW�s Australia�s Health Efficiency, sustainability, capability

8. Indicator framework

9. Equity Considered across the framework: Indicators could be presented for a range of �equity� groups, as appropriate: Indigenous vs non-Indigenous Rural, remote vs capital cities Socio-economic status Public vs private providers Large vs small providers

10. Types of indicators included Definition of Indicators: A key statistical measure selected to help describe (indicate) a situation concisely, track progress and performance, and act as a guide to decision-making not necessarily accurate measures � but required level of accuracy would depend on the purpose Outcome (Example: risk-adjusted in-hospital mortality rates) Process (Example: Assessment of VTE risk) Structure (Example: Accreditation of health care services) Counts/rates/risk adjustment

11. How indicators could be used Comparisons over time/ trends Comparisons for subgroups Indigenous, socio-economic patient groups Providers/facilities/organisations Benchmarking International comparisons A manageable number of indicators

12. �Cascading� indicator sets Necessarily, a �manageable� number of indicators would not provide a detailed view of all aspects of safety and quality for all areas of the health and aged care system. Other indicator sets would remain important to provide more comprehensive views for specific types of services eg Key Performance Indicators for Public Sector Mental Health Services, for safety and quality of care for specialty groups, eg ACHS clinical indicator sets for specific population groups eg the Aboriginal and Torres Strait Islander Health Performance Framework, To provide more comprehensive �balanced scorecards� for health services, including aspects such as efficiency, eg National Health Performance Committee indicators

14. Sentinel events excluded Numbers relatively low, so difficult to use as indicators Important for health care safety and quality Major focus at local level, with incident monitoring Health Ministers require reporting Report on Government Services, Commission Windows report A related structure indicator included Appropriate incident monitoring arrangements, including sentinel events monitoring

15. Public reporting A role of the Commission is to report publicly on the state of safety and quality, including performance against national standards The Commission is developing a strategic framework which will inform its approach to public reporting Broadly, the AIHW suggests two purposes: Informing the general public about the health system overall, and to inform discussion and decision-making about overall priorities and system-level strategies for safety and quality improvement To report on the safety and quality of aspects of specific health care services, to provide information to the providers of the services that would directly inform their quality improvement activities

16. Public reporting Conceptualised as four Levels of application for considering the proposed indicators Health system overall Health care sectors, eg hospitals Facilities/organisations Clinicians The proposed indicators cover all four �levels of application�. The balance may change to suit future approaches to public reporting.

17. Level of application: overall health system, health sector Meaningful to general public and senior policy makers, but ideally also to service providers Focus on international comparisons, population groups, trends over time for Australia Example: 5 year cancer survival rates

18. Level of application: organisation/facility, clinician Meaningful to clinicians and others involved in the delivery of health care service, and ideally to the general public and policy makers Focus on informing local quality improvement activities Support comparisons or benchmarking of service provider organisations Example: Pressure ulcers in care settings

19. Method Scanned lists of indicators used nationally, internationally and by states and territories Consulted with stakeholders � a process that is continuing Including within AIHW�s work to develop performance indicators for Health Ministers earlier in 2008 Consultation with the National Indicators Advisory Group Assessment and analysis of the indicators

20. Summary list of indicators Healthy start (3) Birth trauma � injury to neonate Low birth weight infants Decayed, missing or filled teeth among primary school children Staying healthy (4) Oral health care plans in residential aged care Eye testing for target populations Failure to diagnose Potentially preventable hospitalisations

21. Summary list of indicators, ctd Getting better (33) Assessment of risk of venous thromboembolism Appropriate prophylaxis for venous thromboembolism Appropriate use of antibiotics in general practice for upper respiratory tract infection Ambulance services: survival from out-of-hospital cardiac arrest Pain management in emergency departments Thrombolysis for AMI Thrombolysis for stroke Stroke patients treated in a stroke unit

22. Summary list of indicators, ctd Getting better, ctd Management of AMI Management of congestive heart failure Mental health inpatients having seclusion Health care associated infections acquired in hospital Staphylococcus aureus (including MRSA) bacteraemia in acute care hospitals Adverse drug events Pressure ulcers in care settings Falls resulting in patient harm (health and aged care)

23. Summary list of indicators, ctd Getting better, ctd Intentional self-harm in hospitals Complications of anaesthesia Accidental puncture/laceration (technical difficulty with procedure Obstetric trauma � third and fourth degree tears Postoperative respiratory failure Postoperative haemorrhage Postoperative PE or DVT Unplanned return to operating theatre

24. Summary list of indicators, ctd Getting better, ctd Unplanned readmission to ICU Unplanned hospital readmission Failure to prevent a clinical important deterioration Risk-adjusted hospital mortality Death in low mortality DRGs Independent peer review of surgical deaths Appropriate incident monitoring arrangements, including sentinel events Knee and hip replacement revision within 5 years Cancer survival

25. Living with illness and disability (14) Continuity of care � discharge planning Post-discharge community care for mental health patients Functional gain achieved in rehabilitation Enhanced primary care services in general practice General practices with a register and recall system for patients with chronic disease People with asthma with a written asthma plan Management of hypertension in general practice Summary list of indicators, ctd

26. Living with illness and disability, ctd Management of chronic pain in arthritis and musculoskeletal conditions Annual cycle of care for people with diabetes End stage renal failure in patients with diabetes Lower extremity amputation in patients with diabetes Treatment of depression in primary care Inappropriate co-prescribing of medicines People receiving a home medicine review Summary list of indicators, ctd

27. Summary list of indicators, ctd Coping with end of life (1) Quality of palliative care All health needs domains (3) Quality of community pharmacy services Accreditation of health care services Patient experience � eg treatment with dignity and respect, involvement in decision making, access to information

28. Information presented on the indicators

29. Information presented on the indicators, ctd

30. Information presented on the indicators, ctd

31. Information presented on the indicators, ctd

32. Coverage: Safety and Quality Domains Safety: 25 Appropriateness: 43 Effectiveness: 28 Responsiveness: 7 Continuity of care: 15

33. Coverage: health care needs Healthy start � 3 Staying healthy � 4 Getting better � 33 Living with illness and disability � 14 Coping with end of life � 1 All domains - 3

34. Coverage: health settings Hospitals (40) Primary care (26) Aged care (9) Maternal and child health (5) Dental health (7) Rehab/palliative care (9)

35. Coverage: National Health Priority Areas

36. Coverage: Burden of disease categories

37. Coverage: Areas of health expenditure

38. Coverage: Disease and injury expenditure categories

39. Coverage: Level of application of the indicators Health system (8) cancer survival rates Unplanned hospital readmissions Sector (7) Potentially preventable hospitalisations People receiving a home medicine review Facility/organisation (30) Oral health care plans in residential aged care Self-harm in hospital Clinician (13) Appropriate use of antibiotics in general practice for URTI Complications of anaesthesia

40. Data availability Comprehensive data not available for all indicators, but scope was not limited to current national data sources Reported at national level (28 indicators) Reported by survey (9 indicators) Data development required (12 indicators) Data linkage (4 indicators) Still at concept stage (5 indicators)

41. Support projects Assessment of the feasibility of national indicators of in-hospital mortality (AIHW National Injury Surveillance Unit at Flinders University) A survey of safety and quality indicators relating to primary health care Analysis of Australian data for patient safety indicators developed by the OECD

42. Support project: Measuring and reporting mortality Two components: Literature review on methods for analysis of in-hospital mortality Modelling project aimed at identifying national indicators of hospital mortality that can be used now, or in the future

43. Support project: Measuring and reporting mortality, ctd Literature review Emerging international consensus on risk-adjusted Hospital Standardised Mortality Ratio (HSMR), factors to include for risk adjustment, modelling methods, cases to exclude (eg palliative care) Reported regularly and publicly in several countries Tables, funnel plots, caterpillar plots

44. Support project: Measuring and reporting mortality, ctd Used National Hospital Morbidity Database, and risk-adjusted Canadian Referred Mortality Model (RACM) Logistic regression modelling, including principal diagnosis, age, sex, comorbidity, length of stay, admission status, transfer status Comparison of observed and expected rates Comparison of public hospital peer groups Three groups of cases High risk (less than 20% of cases, 80% of deaths) Low risk (all others) All cases

45. Support project: Measuring and reporting mortality, ctd Results similar to those reported in the international literature Good discrimination of performance between hospitals, particularly larger ones, and consistent over 3 years A modest decline in overall risk-adjusted mortality rates over the 3-year period Demonstration of methods to present findings � HSMR ranked tables, funnel plots, caterpillar plots Demonstrated that NHMD suitable for calculating these indicators for screening purposes Discussion of improvements possible if/when data linkage to capture 30-day post-discharge mortality �Condition onset� flag available to refine the model Private hospital identifiers become available for analysis

46. Support project: safety and quality indicators in primary care Focus on the subset of indicators in the proposed suite that relate to primary care Brief review of primary care indicator suites and indicator reporting nationally and internationally Assessment of the indicators against the framework for this project Most indicators are of appropriateness (and access), fewer for safety and other dimensions Most indicators relate to general practice, few for community health, allied health�.. Mostly process indicators, but some outcome and structure indicators

47. Support project: safety and quality indicators in primary care, ctd Discussion of Australian data sources that are or could be relevant to the proposed primary care indicators Including emerging electronic data collection in general practice Presentation of detailed specifications, rationale and current Australian and international use of each indicator Discussion of methods for presentation Presentation of available data for the indicators using different presentation methods and disaggregations

48. Support project: Australian data for OECD patient safety indicators OECD indicators developed from the AHRQ patient safety indicators, as part of the OECD Health Care Quality Indicators project 15 patient safety indicators piloted with a number of OECD countries Australia participated to assist in assessment of the use of the indicators in the proposed national indicator suite, particularly anticipating needs for international comparisons Translated ICD-10 specifications to ICD-10-AM Analysed using National Hospital Morbidity Database; public/private, public hospital peer groups, 3 years

49. Support project: Australian data for OECD patient safety indicators One not calculable using Australian data; 3 had very small or volatile numbers Remaining 11 were considered suitable for national and international reporting Six included (at least as options) in the proposed indicator suite Technical difficulty with procedure Postoperative PE/DVT Postoperative respiratory failure Birth trauma � injury to neonate Complications of anaesthesia Pressure ulcers Limited risk adjustment in the algorithm, so caution required for sector/peer group comparisons; data suggest casemix-associated differences in rates (eg rates generally higher in the public sector)

50. Next steps AIHW and Commission are consulting stakeholders Receive feedback on proposed indicators Review feedback with the National Indicators Advisory Group Final report provided to Commission in early 2009 Commission to consider and provide recommendations to AHMAC

51. Final report to Commission Recommendations for national indicators Data specifications Current availability and quality of data Data for indicators (where available) Gaps in coverage Need for data development work Options for national reporting/information use Options for international comparison

52. Comments please Gaps Whole of system Specific areas of interest Overlaps, over-emphases Details of the specifications Data sources Usefulness Applicability for various reporting purposes

53. Comments please Secure AIHW website: Discussion paper with draft suite of indicators Primary care indicators discussion paper Draft report on measuring and reporting mortality Draft report on Australian data for OECD patient safety indicators Feedback form To obtain a password to the site: Email: hcsqu-consultation@aihw.gov.au Phone 02 6244 1229 Comments by 9 December 2008