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Clinician-led quality and safety improvement Converting the vision into reality. Ian Scott Director of Internal Medicine and Clinical Epidemiology Princess Alexandra Hospital Associate Professor of Medicine University of Queensland Brisbane Hunter New England Quality Exposition

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clinician led quality and safety improvement converting the vision into reality

Clinician-led quality and safety improvementConverting the vision into reality

Ian Scott

Director of Internal Medicine and Clinical Epidemiology

Princess Alexandra Hospital

Associate Professor of Medicine

University of Queensland

Brisbane

Hunter New England Quality Exposition

Tamworth 16/9/10

quality and safety improvement
Quality and safety improvement
  • Aims
    • To provide safe, effective, efficient, appropriate, responsive, timely, patient-centred care
    • To provide care at the right time to the right person in the right manner
    • To maximise the comfort, dignity and health of a patient’s journey through the healthcare system
  • Which is more successful?
    • Clinician-led vs managerially-led Q+S improvement
  • 3 elements of Q+S improvement
    • Capacity: workforce, infrastructure, skill set
    • Processes: models of care
    • Outcomes: clinical and non-clinical
  • In-hospital care
  • Ambulatory care
  • Generic principles
in hospital care
In-hospital care

Peri-discharge

In-patient

Acute

Transition to community care

Preparation for discharge

Post-discharge

follow-up

Community-based care services and support

Communication to care providers

Initial evaluation

Diagnostic work-up

Clinical stabilisation

Formulation of care

plans

Disposition decisions

Execution of care plans

Completion of comprehensive

assessments

Management of background

medical problems

Avoidance of complications

Patient/carer education

Recovery/rehabilitation

Disposition decisions

Diagnosis and treatment of acute problem(s)

Optimisation of function and physiology

Enabling smooth transition to community care + preventing readmission

proposed service principles
Proposed service principles

QH Statewide General Medicine Clinical Network 2010

proposed service principles1
Proposed service principles

QH Statewide General Medicine Clinical Network 2010

in hospital care1
In-hospital care

Peri-discharge

Acute

In-patient

Initial evaluation

Diagnostic work-up

Clinical stabilisation

Formulation of care

plans

Disposition decisions

Diagnosis and treatment of acute problem(s)

medical assessment and planning units
Medical assessment and planning units

Transferring patients from ED to more suitable medical environment, reducing ED overcrowding

Higher level monitoring for more acutely ill patients

Cohorting of acute medical patients after-hours

Early multidisciplinary assessment

Identification and discharge of short-stay patients

evidence for acute medical units
Evidence for acute medical units

Peer review literature

No controlled trials

Nine before-after analyses of 7 units in UK and Ireland

  • Two studies, one prospective, reported significant reductions in in-patient mortality of between 0.6 and 5.6 percentage points
  • Four studies reported significant reductions in LOS: 1.5 to 2.5 d
  • One study reported 30% decrease in waiting times for patient transfer from ED to medical beds
  • Two studies described significant improvements in patient and staff satisfaction with care
  • Three studies saw the proportion of medical patients discharged directly home from AMU increase by 8 to 25 percentage points
  • Three studies noted no increase in 30-day readmission rates following unit commencement

Grey literature

  • Eight non-peer-reviewed reports relating to 48 units confirmed reductions in length of stay.

Scott, Vaughan, Bell Int J Qual Health Care 2009

plethora of variants
Plethora of variants
  • Acute medical assessment unit (AMAU)
  • Medical assessment and planning units (MAPU)
  • Acute assessment unit (AAU)
  • Acute medical wards (AMW)
  • Acute planning units (APU)
  • Rapid assessment medical units (RAMU)
  • Rapid assessment and planning units (RAPU)
  • Early assessment medical units (EMU)
  • Observation medicine units (OMU)
  • Short stay medicine units (SSMU)
  • Surgical assessment and planning units (SAPU)
integrated hospital emergency care
Integrated hospital emergency care
  • Reconfiguration of EDs into several different functional areas
    • high acuity/high complexity (or critical care areas)
    • low acuity/low complexity patients (observation bays)
    • low to medium acuity/high complexity patients
  • Co-location of medical assessment and planning units (MAPUs) with EDs
    • low to medium acuity/high complexity patients
    • Aim to discharge or transfer patients with 24 to 48 hours
    • Daily, consultant-led ward rounds, early multidisciplinary assessment, and prioritised access to ancillary services
  • Admission avoidance and rapid response community teams within EDs
    • Screen, identify and provide community care for patients who do not need inpatient care
  • Multi-purpose short stay wards adjacent to ED
    • For fully assessed and medically stable patients undergoing treatments or procedures prior to discharge within 24 hours.
  • Dedicated emergency surgical teams
    • Exclusively on call to assess and organise emergency surgery for ED patients
  • Patient pull strategiesby receiving units
  • Streamlined assessment and admission processes
  • Optimal use of transit and discharge lounges
integrated hospital emergency care1
Integrated hospital emergency care
  • Results of redesigned emergency care systems:
    • 16% decrease in acute medical admissions
    • 4% decrease in acute surgical admissions1
  • Australian experiments involving 60 acute hospitals in NSW and Flinders Medical Centre in Adelaide: decreases in ED access block2
  • Boyle et al. Emerg Med J 2008; 25: 78-82.
  • O’Connell et al. Med J Aust2008; 188 (5 Suppl): S9-S13.
integrated hospital emergency care2
Integrated hospital emergency care

Scott IA, Wills R, Watson M, et al Qual Saf Health Care 2010 (under review)

in hospital care2
In-hospital care

In-patient

Acute

Peri-discharge

Older patients with complex needs

High prevalence of cognitive impairment, physical dependency, social isolation

At risk for hospital-acquired complications (delirium, falls, polypharmacy, immobilisation)

Need for high functioning multidisciplinary teams

Need for patient/carer/family education and support

Optimisation of function and physiology

in hospital quality and safety issues
In-hospital quality and safety issues

16 hospitals Issues raised on reviewing deaths 2002-2007

Behal & Finn Acad Med 2009; 84: 1657-1662

failure to rescue
Failure to rescue
  • Strong consistent correlation between risk-adjusted failure to rescue rates and risk-adjusted in-hospital mortality rates for all 6 conditions
    • AMI, CHF, pneumonia, stroke, GI haemorrhage, hip fracture

R = 0.20-0.38; p<0.01

  • Hospitals with best failure to rescue rates had between 22% and 31% lower relative mortality rates across all 6 conditions compared to hospitals with worse rates

4504 US hospitals 2003 PSI data

Isaac et al JGIM 2008; 23: 1373-8

clinical care processes
Clinical care processes
  • Track and trigger systems and rescue responses for deteriorating patients
  • Hand hygiene/barrier nursing/infection control systems
  • Clinical handover systems/continuity of care
  • Interdisciplinary communication and teamwork
  • Evidence-based process of care packages (‘care bundles’) for specific diagnoses
    • AMI, CHF, COPD, stroke, sepsis
    • Hip surgery, PCI, CABG, vascular surgery
  • Prophylactic measures
    • Catheter-associated bacteraemias
    • Surgical site infections
    • Ventilator-associated pneumonia
    • Falls and pressure areas
    • DVT/PTE
  • Medication reconciliation/medication safety practices
  • WHO surgery checklist
  • Infection control systems
  • Palliative care service
  • Post-operative care
  • Family/carer communication
  • Post-death debriefing
clinical care processes1
Clinical care processes
  • Comprehensive assessment of patient risks and proactive prophylactic intervention
  • High-risk patient care areas
    • Patients at high risk of falls, pressure sores, delirium, behavioural problems
  • Regular MDT meetings using patient journey boards
  • Daily morning ward rounds by medical teams
  • Team-based nursing care at the bedside
  • Fast-track access to comprehensive geriatric assessment teams, ACAT teams, other gate-keepers
  • Same day consultant responses for inter-specialty requests for advice on acute management
effects of diagnosis specific care bundles on hsmr
Effects of diagnosis-specific care bundles on HSMR
  • Implementation of eight diagnosis-specific care bundles
  • Central venous catheter/line asepsis
  • Diarrhoea and vomiting
  • Stroke
  • Ventilator acquired pneumonia
  • MRSAinfection
  • Heart failure
  • Surgical site infections
  • COPD

HSMR of 13 diagnoses reflecting care bundles

effects on mortality
Effects on mortality

Physician led improvement teams

Early goal-directed treatment of sepsis

Central line and ventilator bundles to prevent infections

Rapid response teams

Standardised care protocols for cardiac surgery, stroke, etc

Patient safety programs including clinical handover

Feedback to transferring hospitals

Improved clinical documentation and coding

Increased resourcing: nurse levels ICU, defibrillators, intensivists

Hospice-in-the-hospital program

Senior managerial work rounds

Behal & Finn Acad Med 2009; 84: 1657-1662

Greater than average decrease

seen for all US hospitals

Observed total mortality dropped as well

as risk-adjusted index

in hospital general medicine services
In-hospital general medicine services

Peri-discharge

In-patient

Acute

Transition to community care

Preparation for discharge

Post-discharge follow-up

Community-based care services and support

Communication to care providers

Enabling smooth transition to community care + preventing early readmission

readmissions a common problem
Readmissions a common problem
  • 3% to 11% all discharges readmitted within 30 days1
    • 90% unplanned
    • 80% relate to an acute medical complication
    • 60% occur in patients >65 years age
  • Highest readmission rates in US2
    • Heart failure 12.5%
    • Pneumonia 9.5%
    • PTCA 10.0%
    • COPD 10.7%
    • Other vascular 11.7%
    • CABG 13.5%
    • AMI 13.4%

1.Jencks et al N Engl J Med 2009

2. MedPAC, “Report to Congress: Promoting Greater Effi ciency in Medicare,” June 2007; U.S. Department of Health and Human Services, “Hospital Compare,” available at: http://www.hospitalcompare.hhs.gov, accessed September 5, 2009; MedPAC June 2007; Cardiovascular Roundtable interviews and analysis.

patient predictors
Patient predictors

OR

  • Age ≥ 80 yrs 1.8
  • Previous admission <30 dys 2.3
  • ≥5 co-morbidities 2.6
  • History of depression 3.2
  • Living alone
  • Cognitive impairment
  • Functional status
  • Nutritional status
  • Disease severity
  • Longer index LOS
  • Lack of health insurance
  • Residential care
  • Previous readmissions
  • Non-adherence

Marcantonio et al Am J Med 1999

Older patient cohort ≥60 yrs

Thomas & Holloway Med Care 1991

Sullivan J Am Geriatr Soc 1992

Librero et al J Clin Epidemiol 1999

Fethke et al Med Care 1986

Corrigan & Martin Health Serv Res 1992

Smith et al J Clin Epidemiol 2000

Au et al Ann Acad Med Singapore 2002

Silverstein et al Proc (Bayl Univ Med Cent) 2008

predicting patients most at risk of readmission
Predicting patients most at risk of readmission
  • Several attempts at risk prediction models in general acute medical patients
  • Most are not very discriminatory
    • AUROC 0.61-0.70
        • Smith et al J Clin Epidemiol 2000
        • Billings et al BMJ 2006
        • Bottle et al J R Soc Med 2006
        • Howell et al BMC Health Serv Res 2009
        • Hasan et al JGIM 2009
        • Novotny et al Nurs Res 2008
  • Disease-specific risk prediction models
    • Congestive heart failure: AUROC 0.60
        • Ross et al Arch Intern Med 2008
  • Accurate model (AUROC 0.83)
    • requires detailed data on co-morbidities and functional capacity - 20 variables

Coleman et al Health Serv Res 2004

how preventable are readmissions
How preventable are readmissions?
  • 9% to 48% in 7 studies published to 1998
    • Median 16%
          • Benbasset et al Arch Intern Med 2000
  • 5.5% of 437 readmissions JHH
          • Miles, Lowe J Qual Clin Pract 1999
  • 19% of 363 to one Spanish hospital
          • Jimenez-Puente et al Int J Technol Assess Health Care 2004
  • 27% of 390 to 12 US hospitals
          • Halforn et al Med Care 2006
  • 34% of 204 to PAH
          • Scott et al 2001 (unpublished)
  • 33% of 271 to Israeli hospital
          • Balla et al Medicine 2008
how preventable are readmissions1
How preventable are readmissions?
  • In one study of general medicine patients 33% readmissions vs 6% controls had quality of care problems
        • Age and sex adjusted only
    • Main errors
      • incomplete evaluation (33%)
      • too short hospital stay (31%)
      • inappropriate medication (44%)
      • diagnostic error (16%)
    • Most preventable readmissions involved CV event or CHF
    • Mean time to readmission: 10 days
    • Inpatient mortality 6.7% vs 1.7% among readmissions with no QOC problems (p=0.05)

Balla et al Medicine 2008; 87: 294-300

how preventable are readmissions2
How preventable are readmissions?
  • Avoidable complications of care 47%
  • Drug-related adverse events 13%
  • Erroneous diagnosis/inappropriate care 11%
  • Premature discharge 20%
  • Poor discharge preparation 9%

Halforn et al Med Care 2006

reducing readmissions
Reducing readmissions

Discharge planning/preparation

  • Screening for high-risk patients in need of more post-discharge support
  • Multidisciplinary discharge rounds, case conferences
  • Discharge planning protocols and checklists
  • Discharge care plans
  • Patient-carer educational interventions
  • Liaison nurses, discharge co-ordinators, case managers
  • Pharmacist-facilitated discharge program
  • GP input into discharge planning
  • Nurse-led intermediate care units
  • Patient/carer self-management
  • Advanced care plans

Discharge support/aftercare

  • Augmented hospital-primary care communication
  • Post-discharge home visits
  • Post-discharge telephonic contact
  • Post-discharge community support

Hospital avoidance programs

  • Hospital in the home
  • Chronic disease management programs

Scott Aust Health Rev 2010 (in press)

discharge planning
Discharge planning
  • Cochrane review updated Jan 2010
  • Discharge planning defined as:
    • Inpatient assessment and preparation of discharge plan based on individual needs
      • Multidisciplinary assessment involving patient and family
      • Communication between relevant professionals within hospital
    • Implementation of discharge plan
    • Monitoring
  • For elderly patients with medical condition (usually heart failure) readmission rate at 4 weeks reduced by 15%

OR = 0.85 (0.74-0.97)

Shepperd et al 2010

comprehensive discharge planning and post discharge support
Comprehensive discharge planning and post-discharge support
  • RCT; 363 patients ≥65 years (mean age 75 years)
  • Specialist nurse-led assessment, discharge planning, patient-carer education; written care plans and medication lists; discharge summaries; co-ordination of post-discharge services; home visits (24 hrs and 7-10 days), telephonic follow-up
  • Results at 6 months:
    • Readmissions: 20% vs 37% p<0.001
    • Health costs: $0.6m vs $1.2m p<0.001
    • No effects on mortality, functional status, patient/carer satisfaction

Naylor et al JAMA 1999

comprehensive discharge planning and post discharge support1
Comprehensive discharge planning and post-discharge support
  • Meta-analysis of 18 RCT; 3304 patients with CHF; mean age ≥70 yrs
  • Intervention components
    • Specialist nurse or clinical pharmacist-led review
    • Patient education and self-management strategies
    • Discharge planning
    • Written care plans and medication lists
    • Home visits, telephonic follow-up, early clinic review
    • Enhanced communication between providers
  • Results at 8 months:
    • Readmissions: 35% vs 43% RR=0.75 (0.64-0.88)
    • All-cause mortality: 14% vs 17% RR=0.87 (0.73-1.03)
    • % increase QOL score: 26% vs 14% p=0.01
    • Health care costs: No difference

Phillips et al JAMA 2004

comprehensive discharge planning and post discharge support2
Comprehensive discharge planning and post-discharge support
  • Transition coaching
  • Self-management tuition in medication use, relapse recognition, personal health record, timely follow with GPs and specialists
    • Lower readmission rates
      • at 30 days - 8% vs 12%; p=0.05
      • at 90 days - 17% vs 23%, p=0.04
        • Coleman et al Arch Intern Med 2006
comprehensive discharge planning and post discharge support3
Comprehensive discharge planning and post-discharge support
  • Comprehensive nursing and physiotherapy assessment
  • Nurse-led education and self-management strategies
  • Individualised program of exercise strategies
  • Written guidelines for post-discharge care
  • Arrangement of community services and social support
  • Nurse-conducted home visit and telephone follow-up commencing in hospital and continuing for 24 weeks after discharge
  • High risk elderly cohort

At 6 months:

    • Fewer readmissions - 22% vs 47%; p=0.007

Courtney et al J Am Geriatr Soc 2009; 57: 395-402.

improving peri discharge processes
Improving peri-discharge processes
  • A nurse discharge advocate worked with patients during their hospital stay to:
  • arrange follow-up appointments
  • confirm medication reconciliation
  • conduct patient education with individualized instruction booklet that was sent to their primary care doctor
  • Clinical pharmacist called patients 2 to 4 days after discharge to reinforce the discharge plan and review medications

Jack et al Ann Intern Med 2009; 150: 178-187

improving peri discharge processes1
Improving peri-discharge processes

Jack et al Ann Intern Med 2009; 150: 178-187

ambulatory care
Ambulatory care

Hospital-based

clinics

Chronic disease management

End-of-life care

Palliative care

Advanced care planning

Acute care in RACF

Avoidance of hospitalisation

Review of recently discharged patients

Assessment of priority new patient referrals

Secondary and tertiary prevention

Optimisation of disease control, symptom relief, functional capacity

Avoidance of hospitalisation

Holistic care for multi-system disease

Primary/secondary care collaboration

Compassionate and appropriate care at end of life

Timely access to specialist review

Optimisation of function and physiology

proposed service principles2
Proposed service principles

QH Statewide General Medicine Clinical Network 2010

proposed service principles3
Proposed service principles

QH Statewide General Medicine Clinical Network 2010

ambulatory care1
Ambulatory care

Hospital-based

clinics

Chronic disease management

End-of-life care

Improving referrals from GP to specialist

Generally effective strategies included dissemination of guidelines with structured referral sheets (four out of five studies) and involvement of consultants in educational activities (two out of three studies).

The effects of 'in-house' second opinion and other intermediate primary care based alternatives to outpatient referral appear promising.

Akbari et al Cochrane Database Syst Rev 2008

Review of recently discharged patients

Assessment of priority new patient referrals

Timely access to specialist review

ambulatory care2
Ambulatory care

Hospital-based

clinics

End-of-life care

Chronic disease management

  • Intervention designed to manage or prevent a chronic condition using a systematic, evidence-based approach to care and potentially employing multiple treatment modalities
  • Weingarten et al 2002

Optimisation of function and physiology

chronic disease management1
Chronic disease management

Gwadry-Sridhar FH, Archives of

Internal Medicine, 2004, 164: 2315-2320

Gonseth J, et al., European Heart Journal, 2005, 26(3): 314-315

Holland R, et al., Heart, 2005, 91: 899-906

Roccaforte R, et al., European Journal of Heart Failure, 2005 7(7): 1133-1144

Taylor SJ, et al., Cochrane Database of Systematic Reviews, 2005, 2

Clark RA, et al., British Medical Journal, 2007, 334(7600): 942

chronic disease management2
Chronic disease management

Respiratory rehabilitation programs for patients with recent exacerbations of COPD reduce admission rates by up to 87%1

Improve diabetes control; no evidence yet on complications2

CDM items and team care arrangements in primary care have not been as effective as expected3

1. Puhan M, Scharplatz M, Troosters T, et al. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2009 Jan 21; (1): CD005305.

2. Renders CM, Valk GD, Griffin S, Wagner EH, et al. Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings. Cochrane Database of Systematic Reviews 2000, Issue 4. Art. No.:CD001481.DOI: 10.1002/14651858.CD001481.

3. Hartigan et al. Do Team Care Arrangements address the real issues in the management of chronic diseases? Med J Aust 2009; 191: 99-100.

chronic disease management3
Chronic disease management

Klersy et al. JACC 2009; 54: 1683-1694

chronic disease management4
Chronic disease management
  • Co-located specialists in primary care

Gruen et al. Cochrane Database Syst Rev 2004

Nine met the inclusion criteria (RCT, controlled B/A trials, ITS).

Most studies came from urban populations in developed countries

Simple 'shifted outpatients' styles of specialist outreach improved access, but no evidence of impact on health outcomes.

Specialist outreach as part of more complex multifaceted interventions involving collaboration with primary care, education or other services associated with improved health outcomes, more efficient and guideline-consistent care, and less use of inpatient services.

Up to 30% reduction in future events requiring hospitalisation

Additional costs of outreach balanced by improved health outcomes

chronic disease management5
Chronic disease management
  • Co-located specialists in primary care
        • Jackson C, Russell A, Spurling G, et al WCIM 2010
  • Inala CDM Program for patients with complex type 2 diabetes mellitus
  • Community-based general practice with care delivered by a multidisciplinary team of allied health professionals and up-skilled general practitioners who undertook a structured education programme delivered by an endocrinologist who provided ongoing on-site support
  • Evidence based protocols were adopted and individualised care plans were developed for the patients incorporating principles of self-management
  • Service evaluated and compared with a control group of similar patients whose care was provided at the tertiary hospital
  • Significantly greater percentage of patients achieving all 3 targets
    • HbA1c ≤7.0%
    • BP ≤130/80
    • LDL cholesterol ≤2.5 mmol/l

24% vs 10%; p<0.001

  • Sustained funding model needed to maintain new care model
chronic disease management6
Chronic disease management
  • Telehealth
    • Access to ‘live’ interactive specialist consultation
      • under-staffed regional and rural centres
      • RCFs
    • More efficient use of clinics
    • Fewer unnecessary referrals for hospitalisation
        • Patient and referrer messaging
ambulatory care3
Ambulatory care

Hospital-based

clinics

Chronic disease management

End-of-life care

  • Access to palliative care expertise in hospital care
  • Early aged care intervention programs
  • Need for more advance care planning
    • More universal use of advance care directives and palliative care programs in RCFs
      • Reduce hospitalisation rates by up to 40%
          • Molloy et al. JAMA 2000
          • Levy et al. J Palliat Med 2008
          • Badger et al. Palliat Med 2009
      • Shift family/carer expectations towards more conservative care for patients with severe dementia
          • Mitchell et al Engl J Med 2009
principles of q s improvement
Principles of Q+S improvement
  • At multiple levels
  • unit
  • department
  • hospital
  • network

Scott I, Phelps G

Intern Med J

2009; 39: 347-351

what distinguishes successful from non successful hospitals
What distinguishes successful from non-successful hospitals?
  • Use of data and acceptance of data
  • Different departments working together on common agenda
  • Good physician-management relations
    • Good connect between middle managers and senior executives
    • Engagement of clinical departmental heads
  • Engaged quality improvement staff (vs ‘learned helplessness’)
  • Systematic establishment of infrastructure, processes and performance review systems for continuous improvement
  • Strategic alignment and integration of improvement efforts with organisational priorities
  • Active development of clinical champions, teams and staff
  • Absence of an organisational ‘metabolic syndrome’
  • Note: none of the interventions directly targeted hospital’s ‘culture’ or ‘leadership’

Behal & Finn Acad Med 2009; 84: 1657-1662

Wang et al Jt Comm J Qual Patient Saf 2006; 32: 599-611

generic q s indicators
Generic Q+S indicators
  • Standardised mortality ratios
  • LOS – relative stay index
  • Unplanned readmissions
  • Complication rates
  • Critical incidents
  • Complaints
  • Unplanned transfers OT/ICU/CCU/HDU
    • Hospital-wide
    • Diagnosis-specific
    • Unit-specific
  • Pressure areas
  • DVT/PTE
  • Falls
  • Nosocomial infections
  • Medication errors
unit or condition specific q s indicators
Unit- or condition-specific Q+S indicators
  • AMI
    • Process
      • Reperfusion
      • PCI
      • Discharge medications
      • Cardiac rehabilitation
    • Outcome
      • In-hospital death
      • Readmissions
      • 6 or 12-month mortality
  • ……… for other high volume, high risk conditions associated with evidence-based indicators
is all this data being used in the most effective way to drive qsi
Is all this data being used in the most effective way to drive QSI?
  • No – why not?
    • Front-line clinicians rarely see this data
      • If they do they question its validity and usefulness
        • Accuracy of the data is questioned
        • Insufficient sample size
        • Data is not timely or relevant
    • Absence of agreed benchmarks
    • Not used to direct investment in SQI
      • Accreditation
      • Credentialing
      • Marketing
      • Funding applications for more resources
      • Politics
    • No closing of the loop
clinical governance scorecard princess alexandra hospital june 2010
Clinical Governance Scorecard Princess Alexandra Hospital, June 2010

Note: Due to using existing data collection methods, not all data is from the same time periods. Results shown is the most recent available for that indicator

closing comments
Closing comments
  • Professor of Health Architecture Ian Forbes
    • Hospitals (and perhaps all health care services) traditionally have operated rather like a medieval joust, with various groups standing under their shields and operating entirely within their own little worlds
    • What we need is a greater focus on multidisciplinary and multi-team care centred on patient needs (not those of providers), better connectivity between hospital and community teams , and greater use of existing data for facilitating and evaluating quality of care
references
References

Brand C, Scott IA, Greenberg PB, Sargious P. Chronic disease management: Time for consultant physicians to take more leadership in system redesign. Intern Med J 2007; 37: 653-659.

Scott IA, Poole PJ, Jayathissa S. Improving quality and safety of hospital care: a reappraisal and an agenda for clinically relevant reform. Intern Med J 2008; 38: 44-55.

Scott IA. Chronic disease management: a primer for physicians. Intern Med J 2008; 38: 427-437.

Brand CA, Cameron PA, Greenberg P, Scott IA. Health services under siege: the case for clinical process redesign. Med J Aust 2008; 189: 239.

Brand CA, Ibrahim JE, Cameron PA, Scott IA. Standards for healthcare: A necessary but unknown quantity? Med J Aust 2008: 189: 257-260.

Scott IA. Healthcare workforce crisis: too few or too disabled? Med J Aust 2009; 190: 689-692.

Scott IA. What are the most effective strategies for improving quality and safety of healthcare? Intern Med J 2009; 39: 389-400.

Scott IA, Phelps GE. Measurement for performance: getting one to follow the other. Intern Med J 2009; 39: 347-351.

Scott IA, Jayathissa S. Quality of drug prescribing in hospitalised older patients – do we have a problem and can we improve it? Intern Med J 2010; 40: 7-18.

Scott IA. Public hospital bed crisis in Australia: too few or too misused? Aust Health Rev 2010; 34: 317-324.

Scott IA. Preventing the rebound: improving care transition in hospital discharge processes. Aust Health Rev 2010 (in press).