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Inconsistency in Healthcare Practice Excellence

The Department of Health and Human Services of Victoria released a report by Dr. Stephene Duckett. The report reviewed the state of safety and quality in Victorian hospitals. The review delves deep into highlighting hospital governance issues in regard to safety and quality. The report indicates that every modern health system have reported cases where patients suffer frequent avoidable harm when still under care (DHHS, 2016). It is on this philosophy that the report by Duckette identifies several deficiencies in Victorian health facilities on safety and care quality, with recommendations on how to overcome them. This discussion will highlight the different deficiencies highlighted with this review. The discussion will also indicate the National Safety and Quality Health Service standards which relate to the identified deficiencies.

According to the study, one of the deficiencies identified includes the lack of consistency in practice among hospitals in Victoria (Duckett, 2016). The study indicates that health facilities are characterized majorly by pockets of practice excellence. While specialist hospitals in Victoria aim at being the best in the world and as benchmarks, excellence in services is still not steady (DHHS, 2016). The report also indicates that a section of health specialists in Victoria including clinicians aspire to have their work serve as international benchmarks. A lot of them have had their research and/or clinical innovations recognized world over. It is evident that majority of these hospitals in Victoria have a committed leadership fully focused on patient-centered care.  Even so, the report indicates that the facilities have not been able to ensure consistent efforts so that excellence is commonplace in within Victoria Hospitals. In the first place, existing data for comparison purposes indicated that safety has a mixed picture. In this regard, a comparison between Victorian Hospitals and those in South Wales according to the report indicated that Victoria is stronger than its counterpart in terms of quality indicators (adverse effects of drugs) (DHHS, 2016). It is however weaker than South Wales in terms of surgical misadventures. Compared with other states, it was also evident that Victoria is better in hospital facility accreditation as compared to some states in Australia, but also worse than others (Duckett, 2016). The report indicates that majority of Victoria Hospitals seem to have focused more on international acclaim and accreditation in comparison with others across the world rather than committing themselves to their patients. Usually according to Tuan (2015) patients wish to have a lesser risk in regard to avoidable complications as compared to what was the case in other states. The policies and/or ambitions of the department of health in Victoria in regard to care quality and safety did not reflect a full commitment to consistence in excellence.

Inconsistency in excellence in regard to patient safety and care quality can be related to the first NSQHS item entitled “Governance for Safety and Quality in Health Service Organizations.”  One of the criterions under this standard that addresses for sustained efforts in ensuring excellence is one that explains the aspect of “clinical practice.” According to this criterion, it is imperative that clinical health providers offer patients under the guidance of latest best practice and/or evidence based care (ACSQHC, 2012). Apparently, best practice calls for consistency in the provision of healthcare, which must however be based on safety and quality standards appropriate to every patient.  Another criterion under this particular standard emphasizes the need for integrated governance systems structured to manage safety and quality risks for patients (ACSQHC, 2012). This system can help in ensuring that continuous excellence in regard to ensuring the safety and their care quality is sustained.

Information is imperative in the running of a hospital system towards persistent improvement. However, this has not been the case in Victoria hospitals as information has been flowing according to the report (DHHS, 2016).  It was established that most essential data was not; being collected, used, and availed in a form that is convenient. This usually limits the ability of hospitals and clinicians to utilize the information in order to identify any existing opportunities to improve and/or strengthen healthcare. An example is where despite the fact that data on deaths resulting from preventable surgical and/or perinatal processes is collected the department of health and the hospitals usually never access this particular information (Duckett, 2016). It was also established that there exists no standardized data collection on patient outcomes despite the fact that this data can inform one on the progress of the patient’s pain and functionality improvement occurred after treatment.  In Victoria Hospitals, it was evident that central monitoring and feedback on total in-hospital complications is only done for a small fraction of them (DHHS, 2016). From the report, hospital managers in Victoria and the department do not know the total number complaints launched against different individual healthcare practitioners despite the understanding that such complains are very strong predictors in terms of any future issues with particular clinicians. Such issues according to Tuan (2015) can only emerge from ineffectiveness of available data and/or fragmented custodianship of crucial data within the health system. For instance the report indicated that the Victorian Managed Insurance Authority was not able to secure information on patient safety; which it required in order to support health services fully with plans on risk management (Duckett, 2016). In Victoria, there has been widespread reliance on paper-based health information record system as compared to electronic recording systems. Combined with non-existing unique patient identifier this leads to difficulty in tracking the journeys of patients across the hospital system, and/or the analysis of care by use of information from patient records (Duckett, 2016). The department is reported to have missed realizing underperformance cases as a consequence of failure to utilize use detailed data on complications acquired from hospitals, in routine datasets.

Inaccessibility of crucial information on patient safety and quality of care is related to the NSQHS number one entitled “Governance for Safety and Quality in Health Service Organizations.”  The criterion of this standard where this deficiency falls within is one that calls upon health facility management teams to ensure that there is proper incident and/or complaints management from the part of the patients on care (ACSQHC, 2012). The standard dictates that it is important for adverse patient events be identified, recognized, analyzed and reported.  In the case of Djerriwarrh Health Services, it is apparent that the stipulation has not been adhered to especially having seen that there have been minimal identification, reporting and management of adverse events (DHHS, 2016). This deficiency also related to number 5 of the NSQHS. This standard calls for the departmental oversight committees and the management of a health facility to have in place proper patient identification and/or procedure matching means. This according to Duckett (2008) can help in correctly identifying patients so as to also match their identity correctly with appropriate treatment.

According to the report, there exists no effective framework to monitor safety of patients and the quality of care (Duckett, 2016). While there are a number of health indicators including the sentinel event, there is limited timeliness and/or effectiveness of these programs. A case of The Royal Women’s Hospital in Victoria, the Departmental staff agreed that till recently, performance meetings mainly focused on data on budget and activity (DHHS, 2016). Later, the department the scope of such convened meetings to factor in patient care and/or governance issues. Even so, the available data was limited and therefore would not be sufficient enough to be relied on when the department wanted to probe the hospitals’ issues on governance. The report also raises issues against the Australian Commission on Safety and Quality in Health Care. In this regard, the performance monitoring framework of the department was not designed in a way to detect any catastrophic failings as those that had happened at Victoria’s Djerriwarrh Health Services (Duckett, 2016). As a matter of fact, it was apparent that Djerriwarrh had been given excellent scores during performance assessment and further successfully accredited twice within the same period the facility had catastrophic failure in both care and/or clinical governance.

According to the report, a certain independent review had established that the department’s processes could not detect any significant deficiencies in terms of clinical governance at Djerriwarrh (Duckett, 2016). This review further indicated that the department had no robust capacity for undertaking routine surveillance of rampant serious clinical events apart from sentinel events. The department also had poor capacity in regard to responding appropriately to reports on incidents it used to receive. After conducting a broader review of the systems of the department for the rest of the Hospitals in Victoria other than Djerriwarrh, the same conclusion was arrived at (DHHS, 2016).  It was evident that department had immature systems to conduct routine monitoring of safety and care quality. Despite huge volume and/or diversity of existing types of harm within the health system efforts and resources on monitoring are focused mainly on a few safety indicators that have limited usefulness in the clinical context.  The department was by then 9 years behind the leading states in terms of utilizing routine data for monitoring rates of hospital complication. The report established that the department was also 8 years behind in regard to its commitment to establishing special mechanisms to audit clinical governance in the health services across Victoria.  As the last Australian state to implement incident reporting system state-widely, Victoria’s system had been plagued with issues on design and implementation which made it useless to analyze statewide patient safety trends. By the date of the report, about 400,000 incident reports that sat in the department’s system had never been analyzed systematically (DHHS, 2016). Reviews particularly on mortality and/or severe morbidity which are preventable were being carried out by other expert bodies operating outside the health department. These bodies do not share this information with the department and also never inform or investigate Victoria’s unsafe practitioners whenever they are identified (Duckett, 2016). More particularly, the case reviews done by these bodies only investigate different individual incidents but not trends. This limits the usefulness of the reviews in bid to improve safety as highlighted in Tuan (2015). It was established that at Djerriwarrh Health Services, an external consultative council identified preventable deaths two years since the beginning of the cluster of preventable deaths. This councils review processes had not been designed to detect this cluster. It was thus likely that it would have been missed if it were not just for the fact that a member of the council sat on the stillbirth review committee and/or the committee on perinatal mortality. This particular member noticed a huge number of preventable death cases at Djerriwarrh hospital including the similarities that existed between them. Duckett’s report confirmed that the safety and quality of care management system was thus inadequate in terms of establishing rates of avoidable deaths (Duckett, 2016).  Having a dysfunctional system on incident reporting implies that there is no reporting of potentially useful information mainly on recurrent breaches of safety and quality. It also means that even the existing information where obtained, can be misclassified and even lost right before it can reach the department (DHHS, 2016). Limited numbers and/or minimal validity of indicators on performance imply that Victoria hospitals could not be accountable broadly and meaningfully on safety and quality aspects in their practice. The inability to fully use and/or integrate hospital data according to Duckett (2016) also imply that there was failure in fulfilling the department’s main role as manager of the system in the aggregation, integration and analysis of data on safety leading to avoidable patient suffering.

A lack of robust patient safety and care quality monitoring system relates with the first NSQHS standard entitled “Governance for Safety and Quality in Health Service Organizations.” The specific criterion of this standard related to this deficiency is one that emphasizes that it is necessary to implement a governance system which can undertake time-to-time clinical audits (ACSQHC, 2012). These are important in ensuring that governance focuses equally on safety and care quality as well as on other issues regarding a health facility. It is apparent that if these audits would have been place in the majority of Victoria's hospitals, the failures would have been identified and worked upon.

Looking at the failures at the Djerriwarrh Health Services Duckett (2016) indicated that they were all attributed to its board which however later dissolved. While the board was fully responsible for the failures, the ministerial appointment processes including the department’s oversight charged with the role of ensuring overseeing the functions of the board was in question.  These two departmental roles needed to ensure that the boars exercised skills, expertise and even information which were necessary in upholding the facility’s governance responsibilities (Duckett, 2016). The failures occurred despite the fact that Djerriwarrh Health Services facility directors had been recruited using the same process and provided with equal support as those from other boards of public hospitals in Australia. Duckett’s report indicates that this particular highlight of Djerriwarrh was meant to show the probability of similar problems on capacity currently in hospital boards in Victoria. 

The Djerriwarrh Health Services was found to have had avoidable governance failures. It was thus necessary that such a tragedy at the facility needed not to be approached with a “business-as-usual” technique in the quest to manage safety and quality of care for patients (DHHS, 2016). A lot of these departmental failures had also been noticed by three other independent performance audits in the previous decade; yet they still were inadequately addressed by the times the report by Duckett (2016) was being written.  The Auditor-General had noted in then recent report that their audit established systemic failures within the department meaning that there was inadequate leadership and/or oversight that was effective enough.  The issues had been identified back in the year 2005 audit yet the department had done little in providing sufficient priority to the safety of patients more than a decade later. The department has instead focused on instigating further reviews, commissioning of expensive consultancies and further, establishing several committees of experts all of which end up with minimally tangible benefits to patients.

This deficiency is related to NSQHS number 1, entitled “Governance for Safety and Quality in Health Service Organizations.” The deficiency can be addressed under the standard’s criterion which emphasizes on the need for appropriate governance and/or quality improvement healthcare systems. The criterion stipulates that integrated governance systems must be in place so as to manage the safety of patients and related quality risks (ACSQHC, 2012). From the inability of boards to monitor safety and quality of care, it reflects the failure of the department in this regard. This is also in consideration that underperformance cases go unnoticed and this has over time endangered the lives of patients.

From the report, it was clear that different committees of experts within the department were fragmented. Further, they were also insufficiently resourced such that they could not timely detect problems on safety and quality of care for patients so as to carry out follow-up activities towards preventing them (Duckett, 2016). Cultural barriers within the health care facilities also contributed to inability in detecting problems on patient safety and care quality.  In this regard, it was established in several facilities that there was utter discouragement, ignoring, and dismissal of staff complaints. The report indicated that the neither the internal management within the health system nor the regulatory oversight from the department could detect problems and also failed in addressing them.

It is clear that this particular deficiency is related to Standard 1 of the NSQHS which emphasizes the need for “Governance for Safety and Quality in Health Service Organizations.’ Specifically, the inability to detect problems within the health system falls under this standard’s criterion that emphasizes the need for appropriate management of incidents and complaints (ACSQHC, 2012). This is because from the report, incidents involving patient safety and/or quality of care were ignored, left unanalyzed and unused in improving safety systems over time. 

Conclusion

In conclusion therefore the essay above presents a section of the review of Dr. Stephene Duckett’s report. It brings out the main deficiencies identified in the Victorian hospitals in regard to safety and care quality of patients.  The deficiencies include a lack of monitoring tools and capabilities, lack of early problem detection, inconsistency in performance, inaccessibility of important information among clinicians, over-reliance on incapacitated hospital boards among others.   The main NSQHS which the deficiencies relate is “Governance for Safety and Quality in Health Service Organizations.” They tally with the varying criteria under this standard. However, there is one deficiency which relates to NSQHS number 5 which emphasizes on the need for proper patient identification and/or procedure matching means. The standards can be useful in addressing the deficiencies as unearthed by Duckett (2016).

Considering Stephen Duckett’s review of the state of hospital compliance to safety and quality of care standards, it is apparent that there is need for changes particularly in regard to reporting of adverse events. The necessary change should also focus on addressing concerns raised among the staff and from patients within the health facilities. Change is universal and it is very necessary in regard to health care understanding that the latter is dynamic and requires continuous improvement over time (Martin et al, 2012).  Usually, there are internal and/or external factors which influence change.  These factors thus require to be adapted to, and aligned with organizational culture within which new realities are embraced as they emerge in a constant way (Kumar et al, 2015). Change is inevitable especially where new and improved results are required. Main proponents of change theories have insisted that there is need for personal change in order to bring about organizational change. A large section of the population are usually  resistant especially to personal change, understanding well that change requires more time, effort and even persistence.  This is particularly based on the fact that people feel to have lost their old ways, making them redundant, without knowing that change brings about learning new things and growing.  Considering recommendation 2.14.1 of the report by Stephen Duckette (2016), it is necessary for health practitioners to be encouraged to report to their managers any concerns on patient safety and quality of care. It is also important that there is a culture among workers to report any concerns on safety and quality within the health facilities. This presentation will focus on describing an implementation plan that will improve ward culture on reporting concerns on safety and quality of care, in line with principles of change management and various theories of power.

In order to increase the probability of embracing organization change in that it would be effective in a ward or hospital setting, it is imperative that nurses among other health professionals are enlightened on change theories (Mitchell, 2013). Hospital departmental managers and leaders in different healthcare teams should be thoroughly aware of necessary change models in order ensure implementation, compliance and/or follow-up to newly set standards aimed at introducing change in hospital units (Martin et al, 2012). While there are numerous model of change, studies indicate that health care setting requires the infamous Lewin’s model of 1947 and John Kotter’s model. Both of these models can be used in planning improvement approaches in regard to reporting culture on safety concerns in a ward setting.   

Kurt Lewin’s model on change offers managers and change agents a framework to be used in implementing any planned change item. According to the model, there are three stages in implementing change. They include unfreezing, moving and then refreezing as stated in Kumar et al (2015). In regard to the unfreezing stage the model requires that the current situation be assessed after which the workers and/or groups should be convinced on the need for change. This is then followed by the mobilization of resources necessary for supporting the implementation of the change process (Allen, 2016). In this case, the hospital management should convince the nurses and multidisciplinary team working in wards on the need for proactive reporting of concerns on safety and health to the management. The management should introduce methodologies and resources to support this reporting from individual wards in the facility. The unfreezing stage requires that change agents identify problems, decide on the necessary change and creates awareness to others regarding it (Martin et al, 2012). This acts as motivation and at the same time disruption of status quo forces is done. As a result, the affected individuals get unsettled and discounted, leading to the developing of the need for change. Secondly, the moving stage according to the model is where the agent of change (the hospital management), does the identification, planning and implementation of the change items.  At this juncture, a successful unfreezing stage will be realized by where the driving forces exceed any existing restraining forces according to Allen (2016). Change process is dynamic and this means that time remains an important factor. Individual workers in an organizational setting as a hospital will have to assume new tasks and/or responsibilities a factor that will ultimately slow down the activities initially. This will however improve along the learning curve. The third stage of Lewin’s model is the refreezing stage and it includes stabilization if the change process for sustainability purposes (Allen, 2016). There is need for staff members as in the case of a hospital to be supported till there is full acceptance of the change. The success of the change process will be realized at the time the change agent terminates the supportive relationship that was in place (Mitchell, 2013).

Even so, Lewin’s change model is mainly criticized on grounds that it is too simplistic. The three stage approach has also been questioned noting that it is limited changes that are small-scale; in stable conditions according to Allen (2016). According to the critics, the theory is unsuitable for large-scale and/or ongoing change in larger organizations. 

Kotter’s change model can be used in implementing change in large organizations.  The theory proposes eight stages that can be used to plan and implement aspects of change in any given institution such as hospitals. These steps have been discussed below in the light of changing the culture in a ward to ensure that there is proactive reporting of concerns on safety and quality of care in hospitals.

The first step of Kotter’s model involves the creating the need for urgency in regard to change according to Small et al (2016). In this step, staff members need to be motivated in order to welcome the aspects of change through stressing on the need for correcting a particular pressing issue (low reporting of safety concerns). The most effective way in this regard includes identifying any potential threat and the development of scenarios to serve as examples to the members of staff within an organization (hospital).  There is also need for honest discussions including provision of dynamic and/or convincing reasons to make individuals to talk and think about (Ead, 2015). In order to improve reporting culture on safety within the ward, the nurse unit manager (NUM) can for instance, show the ward interdisciplinary team the probability of sentinel events that could result from poor handover practices, and poor communication among them in the ward. This will trigger a sense of urgency among them and bring them to talks and thoughts on best practice and a need for change.

The second step of Kotter’s model requires that a strong coalition be formed in order to convince individuals in an organization that there dire need for change (Kumar et al, 2015). The coalition should be composed of leaders who can influence others to understand that there is need to adopt new ways of doing things (Small et al., 2016). In regard to improving reporting culture on safety within the ward the lead coalition should be developed and have a NUM, resource nurses, educators for nurses, and the facility’s administrative clinical supervisor. It can also include senior nurses within a hospital, who are usually passionate on safety and/or communication.

In the third step, there is need for the change agents to come up with a change vision statement which staff members can easily grasp and remember according to Kumar et al, 2015). There is also need to create different initiatives which will help in achieving the vision set while at the same time communicating appropriately regarding the change (Bradbury, 2014). In this regard, the main vision can be “Improving ward reporting culture on safety and quality of care.” The leaders can enable the staff members to adopt this vision through the use of trigger factors derived from recent adverse experiences among patients and staff members.  

Fourthly, there is need to communicate the change vision effectively in order to sensitize the implementing staff on the change aspects (Appelbaum et al, 2012). In this regard, the what, how and why questions on the proposed change should be addressed by the guiding coalition. In a hospital setting, the ward staff can hold educative sessions and/or staff meetings on weekly basis to address issues on the need for proactive reporting of safety issues (Small et al, 2016).

For the fifth step of Kotter’s model, it is important to empower people to directly and indirectly act on the set vision through involving them (Appelbaum et al, 2012). According to Small (2016), change needs both understanding and enthusiasm from the rest of the team. There is also need for autonomy in adopting and implementing aspects of change where possible. In the case of a ward the interdisciplinary team should be encouraged to provide their suggestions regarding the ways through which organizational culture on safety reporting can be improved within the ward. In case there is need for anonymity, the guiding coalition can provide a suggestion box in which ideas can be dropped for assessment.

The sixth step in this change model requires that short term wins be created through an all-inclusive approach (Appelbaum et al., 2012). The generation and outlining of quick wins helps in creating momentum of the project in that, members of staff are able see immediate effect of the changes and gest motivated (Kumar et al., 2015). In case where step 5 has a good plan being implemented like the strict reliance on a clinical handover framework which can immediately show ward assistants that they are more effective and have fewer mistakes; this will be considered a quick win. Where members of staff are able to complete shifts more efficiently and then leave in good time, this can also be considered to be a quick win.

The seventh step involves the creation of momentum to bring about change through the production of change aspects and building on it (Small et al, 2016). Those organizations which succeed in their support and implementation of change usually improve continuously with a maintained vision according to Bradbury (2014). In regard to the ward setting, the guiding coalition on change should remain proactive in encouraging staff members to keep focus on the vision of change. This brings about openness and/or excitement on the change ideas that could come in the future.

The eighth and last step of Kotter’s model of change emphasizes on the need for institutionalization and solidification of introduced aspects of change in order to make the initially set vision be a norm (Small et al, 2016). The step is imperative in regard to long term success since new behavior can degrade as a result of any alleviation of pressure for change, when not well solidified in time. For the case of the ward, the aspects of the desired change can be taught to any new member of staff including floating staff members in order to make the change foundational in the identity of the unit, making it part of the ward practitioners’ culture.

As a summary, the above theories have different individual pros and cons. Even so, I suggest that the Kotter’s model be adopted in improving the safety reporting culture as it can be effective in large organizations as compared to Lewin’s change theory. Kotter’s change model will also be easier to be followed and it gives a more detailed breakdown of the framework within which change can be implemented in a healthcare setting (Small et al, 2016).  It is adaptable to any given organizational setting and thus can be effective in this particular case.

Theories of power go along with planning and implementation of change in any given organizational setting. Power plays an important role in organizational change according to Stewart et al (2016). Individuals taking part in the change process participate in line with their position within the organization, the power they have in the department and their individual interests. The change process thus must involve discussions on the organizational structure, system structure and power balance within the organization (Ead, 2015). At this point different interest groups within an organization attempt to secure positions of power with different objectives and/or interests. There is normally some reported resistance to change due to power struggles that ensue where individuals try to escape from and/or attain power in the wake of the change (Stewart et al, 2016).  One of the common power theories, include Weber’s theory that is relevant in a healthcare organization setting. According to the theory individuals that possess power like health care professionals need to surrender part of it in order to enhance change in the system to empower users of healthcare services. For the case of implementing a cultural change process in order to improve reporting of safety concerns, it is important for the hospital management to surrender some of its powers to ward nurses and their assistants to investigate and share information on safety and care quality of themselves and that of patients under care.

Conclusion

Victoria’s current healthcare system continues to struggle in regard to safety of patients and care quality. Apparently, the review by Duckette (2016), calls for change within the healthcare system. While people are normally resistant to change there is need to incorporate change and power theories in order create positive impact especially in improving the culture of reporting safety concerns within ward settings in Victorian health facilities as discussed within the above essay. In the essay, the main change theories that can be used in this regard included Kurt Lewin’s theory of 1947 and John Kotter’s theory of 1996. Weber’s power theory has also been used in indicating the relationship between change and power. It is thus important for power balancing in order to bring about a sustainable change process. These approaches as discussed can be useful in improving the culture of reporting safety concerns in a ward within Victorian hospitals an increase the quality of care for patients.  

Reference

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