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Aged Care shortage chokes hospitals

7th Health Services and Policy Research Conference “ You wouldn’t be dead for quids!” 5 December 2011 Chris Baggoley. Aged Care shortage chokes hospitals. Source: The Age, Thursdasy June 2, 2011. HEALTH REFORM - Overview Better coordinated and localised delivery of health services

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Aged Care shortage chokes hospitals

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  1. 7th Health Services and Policy Research Conference“You wouldn’t be dead for quids!”5 December 2011Chris Baggoley

  2. Aged Care shortage chokes hospitals Source: The Age, Thursdasy June 2, 2011

  3. 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

  4. 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

  5. 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

  6. MAJOR EMPHASIS ON PERFORMANCE AND ACCOUNTABILITY • New Performance and Accountability Framework • National Health Performance Authority (NHPA) • Hospital Performance Reports and Health Communities Reports

  7. Emergency doctor: We can't cope ! Hospital ‘overcrowded, overwhelmed’ The Age – 6 October 2011

  8. Wait at hospitals is a test of patients Source: Herald Sun, Thursday June 2, 2011

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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 Access • Targets under the National Partnership Agreement in Improving • Public Hospital Services: Supplementary Annexure. Report to COAG: August 2011 pp 17-18

  16. 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 Access • Targets under the National Partnership Agreement in Improving • Public Hospital Services: Supplementary Annexure. Report to COAG: August 2011 p.23

  17. Access Block and the Introduction of The Four Hour Rule Program in 4 Western Australia Hospitals

  18. Monthly performance against the Four Hour Rule Program in Western Australia **July 2008 – April 2011

  19. 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 Access Targets under the National Partnership Agreement in Improving Public Hospital Services: Supplementary Annexure. Report to COAG: August 2011 p. 56

  20. Clinical Priority Category: 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 Access Targets under the National Partnership Agreement in Improving Public Hospital Services: Supplementary Annexure. Report to COAG: August 2011 p. 57

  21. Percentage of patients by Urgency category (2009-10) 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 p. 56

  22. Guiding Principles • Targets and the changes required to meet them will require commitment right across the health and hospital system • Hospital executives will need to work in partnership with clinicians to achieve sustainable change • Clinical engagement and clinical leadership will be essential if the targets are to be met • Targets must drive clinical redesign with a whole-of-hospital approach • Clinical redesign must ensure patient safety and enhance quality of care • 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 p.13

  23. Guiding Principles • Definitions to be clear and consistent across all jurisdictions • The performance of jurisdictions is not comparable • Progress towards the targets needs to be linked with continual monitoring of safety and quality performance indicators and audit • The impact of targets on demand needs to be monitored and early strategies developed to ensure achievements are sustainable • Quality of training is maintained • 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 14-15

  24. A Consumer Viewof 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

  25. 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

  26. The NSQHS Standards Standard 2 Partnering with Consumers Standard 1 Governance for Safety and Quality in Health Service Organisations Standard 3 Healthcare Associated Infections Standard 10 Preventing Falls and Harm from Falls Standard 4 Medication Safety Standard 9 Recognising and Responding to Clinical Deterioration in Acute Health Care Standard 5 Patient Identification and Procedure Matching Standard 8 Preventing and Managing Pressure Injuries Standard 7 Blood and Blood Products Standard 6 Clinical Handover

  27. ACSQHC: The Australian Quality Improvement Cycle

  28. Antimicrobial Resistance

  29. Time Line of the Rapid Rate of Resistance

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

  31. 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

  32. Australian AMR Plan Animal Agriculture Steering Committee Chair – Chief Medical Officer Members – Chief Execs Food authority Professional organisations • NHMRC • Infection control guidelines • AMR Advisory Committee • - Community acquired • MRSA • Beta lactamases • E coli • - Research priorities • ACSQHC • Prevention Programs • Hand Hygiene • Hospital AMS • Infection control guidelines • Clinical capacity • National Surveillance • PBAC/TGA • Pharmaceutical Benefits Advisory Committee • Regulation • NPS • Campaigns • Community prescribers • Mass audience • 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

  33. Antimicrobial ResistanceQuality Improvement cycle Choice of antibiotic NPS AMS TGA PBAC TGx ACSQHC TGx Uni, Colleges NHMRC ACSQHC NPS Research Translation Infection control Programs AICA NHMRC Surveillance AGAR DUSC NAUSP PHLN BEACH NPS Accreditation DoHA S & T NHPA NAUSP Data ACSQHC Agencies Accreditation

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