Towards high value, high reliability healthcare HMI/IHM Joint Leadership Event 15 May 2009

1. Towards high value, high reliability healthcareHMI/IHM Joint Leadership Event 15 May 2009 Dr. Paul Kavanagh Patient Safety and Healthcare Quality Unit National Hospitals Office, Health Service Executive

2. Overview • The case for change • Why safety and quality? Why now? • The health system response • Commission on Patient Safety and Quality Assurance • The HSE response • The Quality, Safety and Risk Management Framework • Poised for success? • The limits of patient safety • The challenges for health managers

3. Overview • The case for change • Why safety and quality? Why now? • The health system response • Commission on Patient Safety and Quality Assurance • The HSE response • The Quality, Safety and Risk Management Framework • Poised for success? • The limits of patient safety • The challenges for health managers

4. The case for change Source: WHO Health for All Database • Increasing investment demands better performance

5. The case for change • Unsafe and poor quality care is costly • Adverse drug event adds 5 days and $5,000 to hospital episode • Chronic disease - poor outcomes + higher costs = poor value • Value-based healthcare • Consider health outcome relative to cost • Better quality care is more efficient care • Principles • Focus on solutions for patients and families • Focus on treating conditions • Measure outcomes to drive improvement and create trust • Reward value Porter and Teisberg “Redefining Health Care”, 2005.

6. The case for change • More information - rising expectations • Crisis of confidence from high profile failings

7. The case for change Complaints and litigation Source: Clinical Indemnity Scheme

8. The case for change International attention • Harvard Medical Practice Study – NY State 1984 • Healthcare – a leading cause of death and injury* • 1/10 hospital episodes, 1/2 preventable • 1/15 permanent disability, 1/15 death *De Vries et al Qual Saf Health Care 2008

9. Overview • The case for change • Why safety and quality? Why now? • The health system response • Commission on Patient Safety and Quality Assurance • The HSE response • The Quality, Safety and Risk Management Framework • Poised for success? • The limits of patient safety • The challenges for health managers

10. The health system response Commission on Patient Safety and Quality Assurance Established January 2007 Reported July 2008 “Having regard to the findings of the Lourdes Inquiry and to the responses to health system failures in other jurisdictions …. develop proposals for health service wide system of governance based on corporateaccountability for the safety and quality of services”

11. The health system response Learning from the library of reviews and inquiries • Communication with patients when things go wrong – absent or poor • Senior clinical leadership absent, weak management, division • Authority, responsibility and reporting relationships unclear • Team working and communication poor • Adverse event monitoring, analysis and learning underdeveloped • Clinical audit absent • No systems for assuring and maintaining competence Weak and ineffective governance

12. The health system response Why governance?

13. Cadbury’s chocolate • Board in place to safeguard stakeholder interests • Strong leadership given effect by clear accountability • Consumer focus balanced with resource focus • Quality assurance and improvement • Inputs – staff, ingredients, machinery • Processes – standardised using SOPs, managing risks • Outcomes – constant measurement and application of a set of CQI tools, including control charts, benchmarking etc • Balance internal and external controls and assurance

15. Healthcare is a unique business • Principal stakeholders ARE our customers • Aim is health maximisation with fairest distribution within available resources • Highly motivated professional staff • Parallel lines of authority and autonomy • Uncertainty and process variation abound • What works? What is quality care? • Poverty of information

16. Healthcare is a unique business Healthcare needs integrated governance

17. Advocating for positive attitudes and values about safety and quality Leadership, accountability, CQI, quality assurance, ethics focus Planning and organising governance structures for quality and safety Performance review, risk management, AE reporting and management, credentialing, standards Organising and using data and evidence Managing and sharing information and knowledge, supporting clinical effectiveness (EBP and audit), using clinical outcome indicators. Sponsoring a patient focus Participation in healthcare (individual or organisation level), open disclosure, consent, dealing with complaints and concerns Healthcare governance elements

19. Commission Recommendations • Patient and service user focus • Management and leadership • Organisational regulation • Professional regulation • Knowledge and information management

20. Commission Recommendations • Patient and service user focus • Develop involvement in line with national strategy • Management and leadership • Develop leadership to grow a patient safety culture • Clear accountability for quality and safety • Requirement of standards for licensing. • CEO/equivalent - ultimate accountability for quality and safety • Clinical Director - accountability at directorate level. • Boards of management - legal duty for quality & safety oversight. • Vocational competence based training for managers

21. Commission Recommendations • Organisational regulation • Mandatory licensing system, public and private • linked to standards • enforced through inspection and sanctions. • Role of Health Information and Quality Authority. • Professional Regulation • More coherence and coordination between regulators. • Develop and implement a credentialing system to review qualifications and track record of staff at recruitment and ongoing using central database. • Link to clinical privilege delineation at institutional level.

22. Commission Recommendations • Knowledge and information management • Strengthen evidence based practice • Develop clinical audit • Enhance adverse event reporting including mandatory reporting • Recognise importance of health information, advance the National Health Information Strategy and commit to the electronic health record.

23. Overview • The case for change • Why safety and quality? Why now? • The health system response • Commission on Patient Safety and Quality Assurance • The HSE response • The Quality, Safety and Risk Management Framework • Poised for success? • The limits of patient safety • The challenges for health managers

24. The HSE response - context Quality and Fairness 2001 • Better Health for All • Fair Access • Responsive & Appropriate Care • High Performance 6 frameworks for change 182 mentions of quality Most external QA

25. Since 2005 • Internal • Fading out of health board structures including quality and risk • Establishment HSE structures for quality and risk • Plans for a Directorate for Quality and Clinical Care • External • Fading out of accreditation system, establishment of HIQA • Commission on Patient Safety and Quality Assurance

26. Quality & Risk Management Standard (OQR 009 - 2007) • Statement of standard: ‘Healthcare quality and risk are effectively managed through implementation of an integrated quality and risk management system that ensures continuous quality improvement.’ • Criteria reflect a system of internal control for healthcare organisations • The risk management aspects of which conform to the requirements of the Australian/New Zealand risk management standard AS/NZS 4360:2004, which has been formally adopted as the process for managing risk in the HSE

27. NHO response to HSE Standard Safer, better care & services

28. The overarching strategy for implementing the HSE Quality and Risk Standard in all services managed or funded by the HSE. Developed carefully with collaboration, consultation and piloting. The objectives of the strategy are to: ensure that there is an appropriate framework for quality, safety and risk management in place across all HSE service providers drive core work programmes in quality, safety and risk management ensure that appropriate accountability and oversight arrangements are in place for monitoring quality, safety and risk management and to support the provision of assurances. Integrated Quality, Safety and Risk Management Framework

31. Assuring quality and risk in HSE…. Quality & Risk Framework CEO & Board Assurance

33. Overview • The case for change • Why safety and quality? Why now? • The health system response • Commission on Patient Safety and Quality Assurance • The HSE response • The Quality, Safety and Risk Management Framework • Poised for success? • The limits of patient safety • The challenges for health managers

34. “It is not correct to say the (Fitzgerald) Report foreshadows “the proposed closure of so many hospitals”. What it does is to suggest a change in the function to be assigned to certain of our hospitals. The report sets out the principles which should govern the future development of the hospital services if we are to keep in step with modern advances in medical knowledge and techniques … necessary in a first-class modern hospital service dealing with serious conditions.” Erskine Childers, Q&A Fitzgerald Report Dáil Éireann15 July, 1969. Limits of patient safety? 204 mentions of safe or safety

35. Limits of patient safety? • The right debate? • Public discourse on patient safety outweighs quality • Constructed as preventable personal tragedy • Evokes fascination, outcry, demand for zero tolerance • Premise of preventability – solid foundation? • Implicit and unreliable assessment of preventability • Eludes easy measurability • Challenges zero tolerance and accountability “….but no-one was held to account” Troyen A. Brennan & Atul Gawande New Eng J Med 2005

36. Patient Safety Individualistic Decibels skew priorities Weak evidence base on cause and effect Hard to measure and less predictable impact Bolt-on Value of AE reporting? Healthcare Quality Population-based Rational prioritisation Strong evidence base on cause and effect Measurable and more predictable impact Core business HIT and EHR Limits of patient safety? Treat safety as a quality domain and drive up quality

37. Challenges for health managers • Leadership – everyone has a role • Working with clinicians in management • Accountability for quality and safety • Boards of management • License holding • Credentialing and privileging – supply of staff “When the music changes so does the dance”

38. Challenges for health managers Healthcare in Ireland is changing Over run & quality regulation LHO Manager Hospital Manager Cost & quality control

39. Prevention Early detection Right diagnosis Early treatment Right treatment to the right patients Treatment earlier in the causal chain of disease Fewer mistakes in treatment Fewer delays in the care delivery process Less invasive treatment methods Faster recovery More complete recovery Less disability Fewer relapses/acute episodes Slower disease progression Less need for long term care High reliability healthcare isHigh value healthcare Better quality improves efficiency in health care

40. Overview • The case for change • Why safety and quality? Why now? • The health system response • Commission on Patient Safety and Quality Assurance • The HSE response • The Quality, Safety and Risk Management Framework • Poised for success? • The limits of patient safety • The challenges for health managers