Towards high value high reliability healthcare HMIIHM Joint

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

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

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

The case for change l Unsafe and poor quality care is costly – – l 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 l l 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.

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

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

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

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

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 corporate accountability for the safety and quality of services”

The health system response Learning from the library of reviews and inquiries l l l l 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

The health system response Why governance?

Cadbury’s chocolate l l 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

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

Healthcare is a unique business Healthcare needs integrated governance

Healthcare governance elements 1. Advocating for positive attitudes and values about safety and quality – 2. Performance review, risk management, AE reporting and management, credentialing, standards Organising and using data and evidence – Leadership, accountability, CQI, quality assurance, ethics focus Planning and organising governance structures for quality and safety – 3. 4. 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

Commission Recommendations l Patient and service user focus l Management and leadership l Organisational regulation l Professional regulation l Knowledge and information management

Commission Recommendations l Patient and service user focus – l Develop involvement in line with national strategy Management and leadership – – Develop leadership to grow a patient safety culture Clear accountability for quality and safety l l – 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

Commission Recommendations l Organisational regulation – Mandatory licensing system, public and private l l – l 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.

Commission Recommendations l 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.

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

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

Since 2005 l Internal – – – l 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

Quality & Risk Management Standard (OQR 009 - 2007) l 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. ’ l Criteria reflect a system of internal control for healthcare organisations l 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

NHO response to HSE Standard Safer, better care & services

Integrated Quality, Safety and Risk Management Framework 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: l ensure that there is an appropriate framework for quality, safety and risk management in place across all HSE service providers l drive core work programmes in quality, safety and risk management l ensure that appropriate accountability and oversight arrangements are in place for monitoring quality, safety and risk management and to support the provision of assurances.

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

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

20 4 m en tio ns of sa fe or sa fe ty Limits of patient safety? “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 Éireann 15 July, 1969.

Limits of patient safety? l The right debate? – – – l 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

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

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

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

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

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