Leaping off Laurels

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Leaping off Laurels

• Susan Dovey

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What this talk is about

• For decades new Zealand has enjoyed resting on
  the laurels of the ACC, but has that contributed
  to entrenched complacency about patient safety?
• Are we so enamoured with this Good Thing that we
  are blind to anything else, and unable to follow
  where other countries are now leading?

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Plan for this talk

• A story about fires
• A story about our NZ health system
• A story about other countries and patient safety
• A discussion about how we might leap WITH our
  laurels

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Fires

• Dr Donald Berwick, Harvard School of Public
  Health
• Mann Gulch fire, August 4 1949
• escape fire prevention

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Ingredients of the US fire

• Uncontrolled escalation of healthcare costs
• 5of GDP in 1963 15 in 2005
• A medical-industrial complex undermining the
  professional values of physicians
• Of 23 OECD countries, the US had the highest
  infant mortality rates
• The US ranked among the bottom of OECD countries
  on healthy life expectancy at age 60
• 98,000 Americans die annually from medical errors
  in hospitals
• A series of malpractice crises

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• Malpractice crises highlight deeper problems
  in our current liability system and the need for
  better solutions. The liability system does not
  compensate patients in an equitable way nor does
  it effectively deter medical errors or encourage
  participation in patient safety initiatives such
  as adverse event reporting.
• Williams CH, Mello MM. Medical malpractice
  Impact of the crisis and effect of state tort
  reforms. Robert Wood Johnson Policy Brief No 10,
  May 2006

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Lessons for the US health system from Mann Gulch

• We need to face reality
• Drop the Pulaskis
• Stay in formation
• Talk to each other and listen
• Leadership

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Ingredients of New Zealands Escape Fire

• Our size
• Our health system structure
• Our ACC

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Whew!!!
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We also need to face reality

• Infant mortality 2006
• United States 6.37 41st
• New Zealand 5.67 35th
• Taiwan 5.54 34th
• Greece 5.34 32nd
• United Kingdom 5.01 28th
• Canada 4.63 22nd
• Australia 4.57 19th
• Japan 2.80 3rd
• Sweden 2.76 2nd
• Singapore 2.36 1st

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Patient safety is a problem in NZ

• 182 sentinel and serious adverse events
  (including 40 deaths) in NZ public hospitals
  2006/07
• 1 research study, published in 2002
• Adverse event in 10.37 of admissions
• 4.5 of adverse events death
• Given 834,843 admissions, maybe 86,000 adverse
  events and 4000 deaths
• 5-10 times more likely to die from medical
  misadventure in our hospitals than by a traffic
  accident

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What are other countries doing that we are not?

• National patient safety strategies in many
  countries
• Finding out about threats to patient safety and
  how to remove them
• RESEARCH
• Teaching health professionals about patient
  safety
• Monitoring and surveillance

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What are we doing that other countries are not?

• Telling ourselves that we dont have a problem
• Focusing on our systems for dealing with
  patients complaints as a means of improving
  patient safety

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Patient safety in primary carewhat do we know?

• Only 49 English-language research papers
• Almost all primary care research comes out of
  Australia, the US, and the UK
• 1 paper from NZ (part of an international study)

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What we know

• Reporting systems are most common way to collect
  safety event data
• Incident reporting systems have been trialed and
  are acceptable to primary care providers
• the National Reporting and Learning System in the
  UK is the only national safety event reporting
  system accessible to primary health care workers
• The language is a problem
• Adverse Events in 0.75 to 80 per 100,000
  consultations
• (NZ 145 to 15,440 Adverse Events)
• Preventability 4.3 83 of all errors
• Clinician attitudes to safety event reporting are
  positive

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What we dont know

• Much about patients their perceptions of patient
  safety issues, their contributions to safety
• Prevalence of patient safety problems
• International differences
• Characteristics of safe/unsafe general practices

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More of what we know

• A central focus on primary care is
• NECESSARY
• Most people receive most health care in primary
  care
• Patient safety events in hospitals can be averted
  in primary care
• CHALLENGING
• In its diversity
• In its dependence on private funding
• In its variety of governance (infra)structures

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Its NECESSARY because

• 3.4 million people visit a GP per year
• X
• 5.68 visits pppa
• 19.3 million GP consultations p.a.
• X
• 1.8 problems / consultation
• 34.7 million treatment plans /year
• each could be a safe decision, OR NOT
• Statistics NZ December 2007, NatMedCa, HSRC
  Evaluation of PC Strategy

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What is RNZCGP doing for GP teams ?
DHB / Sector / HSC
PHOs / OGP
Cornerstone / A4X
Professional / MOPS
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What could strengthen Patient Safety in Primary
Care ?

• A NZ patient safety strategy reflecting a primary
  care led health system (the Primary Health Care
  Strategy)
• Finding out about threats to patient safety and
  how to remove them
• RESEARCH
• Teaching health professionals about patient
  safety
• Monitoring and surveillance

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Where are we coming from ?
Occasional statement and media releases
Promoting SAFE practice in healthcare
Sentinel EventReporting by healthcare
professionals in some hospitals and primary
care practices
ACC treatmentinjuries
Identifying UNSAFE practice in healthcare
Patient complaints to the Health and Safety
Commissioner
Dealing with HARM
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Whats wrong with this model?
? REACTIVE rather than PROACTIVE
? driven by HARM rather than SAFETY
? FRAGMENTED rather than COHESIVE
? INDIVIDUAL engagement rather than UNIVERSAL
responsibility
? AVOIDING (GUILT) things that go wrong vs
EMBRACING prevention before harm happens
? TOP DOWN rather than BOTTOM UP
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Where could we go to?Taking our focus from the
Ambulance at the bottom of the Cliff the
fence at the top of the cliff
Safety Commissionerpromotes safe practice
derived from
Occasional statement and media releases
Promoting SAFE practice in healthcare
RESEARCH to define safe practice
Sentinel EventReporting by healthcare
professionals in some hospitals and primary
care practices
Identifying UNSAFE practice in healthcare
ACCtreatmentinjuries
Other
SentinelEvent reporting
Significant Event reporting
ACCtreatmentinjuries
ACCtreatmentinjuries
ACCtreatmentinjuries
Other
Consistency of definitions
Patient complaints to the Health and Disability
Commissioner
HDC
HDC
Dealing with HARM
ADDITIONAL
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THANK YOU
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What can we do together to make progress?

• Trust
• Informed and committed dialogue
• Action with integrity
• Stronger trust
• Increasingly rapid and effective action

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Simplicityon the other side of complexity 

• I would not give a fig for the simplicity on
  this side of complexity, but I would give my life
  for the simplicity on the other side of
  complexity
• Oliver Wendell Holmes Jnr

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How big is the risk in NZ ?

• International Primary Care Adverse Events
• Makem M, Dovey S. Report to WHO World Alliance
  for Patient Safety.
• Patient Safety Methods and Measures used for
  Research in Primary Care (In Press), December
  2007.

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What value can general practice add?

• A General Practice Quality System RNZCGP
  supporting professional and practices

Professional
Team
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SEA in A4X in Cornerstone
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Back to NZ
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Situational limits on quality/safety

• Undifferentiated problems / patients not
  practised in the story
• Time pressure and affordability expectations
• Limited access to diagnostics
• Limited access to more than one clinician at any
  one time
• Multiple different GPs and nurses
• Poorly monitored home settings
• Multiple agencies with limited coordination
  ability
• 3 Question
• Is there a risk? How big? In the NZ
  setting?