A policy is a statement of intent, or a course or principle of action. Australia’s national health care policy is overseen by the Australian Government, with key elements (such as the operation of hospitals) operated by state governments (DHHS, 2016). In essence, the Australian Government has primary responsibility for community and public health. In Victoria, this is overseen by the Department of Health and Human Services. Their motto is to “aspire for all Victorians to be healthy, safe and able to lead a life they value”. They “deliver policies, programs and services that enhance the health and wellbeing of all Victorians” (DHHS, 2016).
In March 2015, a cluster of perinatal deaths that had occurred during 2013 and 2014 at Djerriwarrh Health Services was brought to the attention of the Department of Health and Human Services (the department) by the Consultative Council on Obstetric and Paediatric Mortality and Morbidity (CCOPMM). After it was found that seven of these deaths were potentially avoidable, an independent review was conducted by the Australian Commission on Safety and Quality in Health Care (ACSQHC) into the department’s actions in relation to these deaths and to examine the department’s capacity to detect and respond to emerging critical issues in the public health system. Post evaluation, the ACSQHC, identified significant issues and found that in respect to Djerriwarrh, significant deficiencies in clinical governance were not detected, and worse, that the departments processes were not capable of detecting these deficiencies. In light of these findings, the Minister for Health requested the review by Dr Stephen Duckett to:
Review the department’s current systems for governance and assurance of quality and safety in hospitals; and
Where systems were found to be inadequate, to provide advice as to how these systems may be improved.
Despite the incidents occurring at Djerriwarrh health service, these are considered to be symptoms of a broader problem. The review is revealing, enlightening and comprehensive and will affect all hospital and health care services. The recommendations are many, and about serious change.
Major deficiencies addressed
It was found that the department’s oversight of hospitals is insufficient. It was also found that the department does not have the information it needs to assure the Minister and the public that all hospitals are providing consistently safe and high-quality care (DHHS, 2016).
The major deficiencies in health care that have been identified and addressed by this review, along with the related NSQHS are as follows:
1.A lack of reporting errors and adverse patient events. This was made evident due to the finding that the department “does not have a functional incident management system for hospital staff to report patient harm” (DHHS, 2016, p13). Complaints of the system are that The Victorian Health Incident Management System (VHIMS) is difficult to use, poorly designed and excessively complex. For example, the current “incident classification component of the system has more than 1400 different types of incidents that users need to select from, making selecting an appropriate classification time consuming and complex. This also means that users may classify incidents inappropriately or select generic classifications like ‘other’ to save time” (DHHS, 2016, p107). It was found that all reports related to the tragedies at Djerriwarrh were not made accurately or on time. However, regardless, it has also been identified that the department was not monitoring and analysing the incident database and so would not have detected them anyway (DHHS, 2016). “A dysfunctional incident reporting system means that potentially useful information about recurrent safety breaches is often unreported, misclassified or lost before it reaches the department” (DHHS, 2016, p14). Additionally, it was found that the “departments performance monitoring framework is not designed to detect catastrophic failings” (DHHS, 2016, p13).
The NSQHS that this major deficiency relates to is standard number one ‘Governance for Safety and Quality in Health Service Organisations’ (NSQHS, 2012). This particular standard has certain criteria that must be met in order to achieve this standard. One of which is about incident and complaints management, specifically, that adverse events are recognised, reported and analysed. It is clear from the deficiency identified, that this criteria has not been effectively met by Djerriwarrh or the department.
2.The department’s expert committees are fragmented and many are not resourced to detect problems in a timely manner or to follow up to stop them happening again (DHHS, 2016). Additionally, cultural barriers to reporting have been identified (DHHS, 2016). For example, it was found that staff complaints were discouraged, ignored, or dismissed. It was also found that both internal management and regulatory oversight either did not detect the problems or failed to address them (DHHS, 2016).
The NSQHS that this deficiency relates to is standard number one ‘Governance for Safety and Quality in Health Service Organisations’. The particular criterion that has been breached in relation to this standard is related to incident and complaints management. It is clear that patient safety and quality incidents were ignored and clearly were not reported correctly, analysed and thus not used to improve safety systems (NSQHS, 2012)(Miller, 2013).
3.The department has over-relied on accreditation when the evidence suggests that is not justifiable (DHHS, 2016). For example, Djerriwarrh Health Services was consistently identified as a high performer, gaining top scores at the end of 2012-13, and it was found that the department had no concerns until early 2015, at which point seven potentially avoidable deaths had already occurred. A series of factors contributed to this failure however, poor clinical governance is to blame and ultimately the department had over-relied on accreditation. Disturbingly, this clinical governance failure at Djerriwarrh was found to be a risk that could easily occur at any hospital or health service (DHHS, 2016).
The NSQHS that this deficiency relates to is standard number one ‘Governance for Safety and Quality in Health Service Organisations’. This particular standard has certain criteria that must be met in order to achieve this standard. One of which states the necessity for implementing a governance system that undertakes regular clinical audits (NSQHS, 2012). This has clearly not been effective as if regular effective audits were undertaken, then the failure in clinical governance would have been identified.
4.The department is lacking in the use of routine data that has been collected in order to monitor hospitals’ complication rates (DHHS, 2016). Clinicians and hospitals cannot access critical information as essential data is not collected or is not made available in a convenient form. Additionally, it was found that much routine data is collected, however the department does not access it often enough to monitor patient outcomes and investigate red flags. Within routine datasets, the department has failed to fully access and use detailed information on hospital-acquired complications meaning cases of underperformance have been missed.
The NSQHS that this deficiency relates to is standard number one ‘Governance for Safety and Quality in Health Service Organisations’ (NSQHS, 2012). A criterion of this standard is related to governance and quality improvement systems, stating that there must be integrated systems of governance to actively manage patient safety and quality risks (NSQHS, 2012). Clearly, the department has failed in this aspect as red flags and cases of underperformance have gone unnoticed, subsequently placing patients at risk.
5.In the public sector, the department expects and relies too heavily on hospital boards to ensure care is safe and continuously improving (DHHS, 2016). The department also does too little to ensure that all boards are equipped to exercise this function effectively (DHHS, 2016). This is a reflection that the department’s overarching governance of hospitals is inadequate. It has been found that the department was not placing enough priority to patient safety. The review discusses in detail the disparities within hospital boards between small and large hospitals, differing opinions of CEOs and financial teams, however that is not the scope of this essay. The bottom line is, that the department was not doing enough to be involved with, understand and even pick up on these disparities, at the expense of patient safety and continuous improvement in health care.
The NSQHS that this deficiency relates to is standard number one ‘Governance for Safety and Quality in Health Service Organisations’ (NSQHS, 2012). There are two criterion to meet this standard that have been breached. The first one is that of governance and quality improvement systems. Integrated systems of governance to actively manage patient safety and quality risks has clearly been breached in this respect. Additionally, the criterion of incident and complaints management has also been breached as patient safety incidents are not recognised, reported and analysed at all levels of the healthcare system.
6.Similarly, to point number six, in the private sector, the department relies even more heavily on local governance (i.e. hospital boards) to ensure that care is safe and continuously improving (DHHS, 2016). It was also found in the private sector that the department conducts no routine monitoring of patient outcomes or serious incidents (DHHS, 2016). Currently, private hospitals are not subject to the same reporting requirements as public hospitals, and almost no data is collected, monitored or fed back to private hospitals about their safety performance.
The NSQHS that this deficiency relates to is standard number one ‘Governance for Safety and Quality in Health Service Organisations’ (NSQHS, 2012). Similarly to point number six above, two criterion to meet this standard have been breached. The first one is that of governance and quality improvement systems and the other is the criterion of incident and complaints management (NSQHS, 2012).
In both sectors, the department could and should be doing much more to ensure that hospitals do not provide care when it is outside their capability to do so (DHHS, 2016).
7.The department has not been supportive enough of hospitals and has provided too little leadership in respect to safety and quality improvement (DHHS, 2016). It was found that the department has not offered continuous support or sustained investment in the right resources that hospitals need. Hospitals are often left to create their own approach to safety and quality improvement, leading to duplication of work, variation in quality and inefficiency (DHHS, 2016). It was also found that high quality information is not being developed or shared and therefore, hospitals are not able to learn from each other. Ultimately, the department is not offering a strong enough system and is not offering the right resources, information and incentives for hospital clinicians and executives to offer the best possible care. Additionally, it was found that there is a lacking in communication between external expert bodies and the department regarding the sharing of information, and more prominently, the identification of unsafe practitioners (DHHS, 2016).
The NSQHS that this deficiency relates to is ‘Governance for Safety and Quality in Health Service Organisations’(NSQHS, 2012). Two criterion to meet this standard have been breached. The first one is ‘clinical practice’. This criterion states that care provided by the clinical workforce must be guided by current best practice. Clearly, if hospitals are developing high quality information, but this is not being shared between hospitals, then it is not likely that all clinicians are operating under current best practice.
The second criterion that has been breached is ‘governance and quality improvement systems’(NSQHS, 2012). This criterion states that ‘there must be integrated systems of governance to actively manage patient safety and quality risks’. The departments overarching governance in terms of providing necessary resources to hospitals and clinicians has been inefficient.
In a broad sense, it is likely that the department’s deficiencies relate to all of the current NSQHS standards. These include preventing and controlling healthcare associated infections, medication safety, clinical handover, blood and blood products, preventing and managing pressure injuries, recognising and responding to clinical deterioration in acute health care and preventing falls and harm from falls (NSQHS, 2012). Ultimately, however, they all come down to a major deficiency in clinical governance. The review defines clinical governance as the “systems and processes that health services need to have in place to be accountable to the community for ensuring that care is safe, effective, patient-centred and continuously improving” (DHHS, 2016, p3). The review found that the department’s processes, at Djerriwarrh, and more broadly, all hospitals, were not capable of detecting significant deficiencies in clinical governance.
Additionally, these deficiencies and issues with clinical governance are not isolated to Victoria. A literature review found many articles outlining similar problems within health care systems relating to clinical governance and quality and safety of patient care (Atsalos, O'Brien, & Jackson, 2007; Robinson, Travaglia, & Braithwaite, 2008; Tuan, 2015). In Victoria, it has been suggested that the health care system does not require major reform (Duckett, 2008). It is acknowledged however, that change is required at a macro level in the roles of Commonwealth and state governments and on a micro level, amongst health care providers (Duckett, 2008).
Part two - change management
It is clear from the analysis of Stephen Duckett’s review that major change, with the immediate focus of health care concerns, within the department is dearly necessary. Change is a necessary part of health care. Change is influenced by both external and internal factors and is required to adapt and align the organisation with new realities that are constantly emerging (Kumar, Kumar, Deshmukh, & Adhish, 2015). For example, technological advances, demand for quality assurance, epidemiology of diseases emerging and re-emerging, era of evidence based policy, health and medical care, privatisation and commercial interests and health as a human right (Kumar et al., 2015). In summation, for an organisation to survive, it must adapt to changing conditions.
Change is not an easy thing to implement or carry through, especially in a long lasting way. Organisational change “requires personal change in an organisational setting” (Carlopio & Andrewartha, 2008, p.496). A lot of people are resistant to personal change. It takes effort, persistence and time. Often there can be a sense of loss as old ways of doing things become redundant, however with change we adapt, learn and grow.
Research has shown that healthcare sectors often experience challenges associated with implementing change effectively (Allen, 2016). These challenges include difficulty in motivating employees to change, communicating the need for change effectively and sustaining any improvements that the change has achieved over time (Martin, Weaver, & Currie, 2012). It is recognised that the complexity of the health care system that makes the process of change most difficult (Allen, 2016).
Change can refer to macro change and micro change. In respect to health care and the Victorian health care system, macro change can refer to overall change in the health care system, or at an organisational level. Micro change can refer to a specific work unit or department. In respect to the Victorian health care system, macro change is needed at the overall health care system level, starting with the department. This will hopefully create a ripple effect right down to the micro changes in service delivery and bedside care. All of these changes however require proper change management (Currie & Loftus-Hills, 2002; Kumar et al., 2015).
To increase the likelihood that organisational change will be effective, it would help if nurses and other health professionals have knowledge of theories and models of change (Mitchell, 2013; Price, 2008). This is especially applicable to managers and particularly leaders within the health care setting as these are the people who will most likely be instigating and implementing the change.
There are a multitude of theories that can be used to implement organisational change (Allen, 2016; Freshwater, 2014). There are two models, however that appear to be most applicable to implementing change in health care. Most contemporary theories and models are adaptations from the work of Kurt Lewin (1947) and his classical three stage change model. John Kotter (1996) however, created an eight step change model based on Lewin’s three step process that has been identified as successful (Kumar et al., 2015). Both models have been summarised below, however it is Kotter’s (1996) model that will guide the reader in how a plan could be implemented to improve the reporting culture on a ward based around safety concerns.