Tuesday, July 30, 2013

“Hands on Forum” Report

On 1 May 2013, as a representative of the Health Care Consumers’ Association, I attended the Hands on Forum – a community consultation for the ACT Ministerial Advisory Council on Women on the ACT Women’s Plan 2010-2015.  The Women’s Plan outlines the ACT Government’s vision for improving the status and lives of women and girls in the ACT.  This vision is to value and invest in women and girls and promote and safeguard the freedoms and rights necessary for all women and girls to actively participate in all areas of Canberra life.  The plan outlines objectives for three identified priority consultation areas – economic, social and environmental.  The forum involved an introductory speech on each of these areas followed by facilitated group discussion highlighting suggestions to address concerns in each area. 

Speaker: Rebecca Cassells, Principal Research Fellow and Leader, Women, Children and Families, NATSEM, University of Canberra.
The economic strategic outcome is for women and girls to equally and fully participate in and benefit from the ACT economy.  The indicators of progress in this area are:
  • pathways for women and girls in education and training;
  • increased opportunities for the advancement of women in the workforce;
  • increased economic leadership and decision making opportunities for women and girls; and
  • improved financial equity.

Rebecca gave a snapshot of the economic environment for ACT women.  The ACT has the highest labour force participation of men and women in Australia, including more stable employment, low unemployment, low working hours and low travel time. The ACT economy is dominated by the public service with a highly educated workforce, a low gender employment gap and the highest standard of living in Australia.  

Overall, ACT women are generally doing better than the rest of Australia, but problem areas include work/family balance, significant hours of unpaid work, wage gaps (particularly due to part-time work) and the trend of poorer economic positions of older women, indigenous women, linguistically and culturally diverse women, and women with disabilities. Implications of lower wages for women include less current and future economic security, lower standards of living for women and their children, decreased lifetime earnings and accumulation of wealth for retirement, and increase welfare reliance. 

Forum participants were asked to give responses in relation to 4 key economic themes. Suggestions included:
  1. Affordable Housing – greater access to government loan assistance, particularly for women working part-time or at home with children, and more community housing.
  2. Affordable Childcare – more centres and places available, access to subsidies across a wider range of child care services, more workplace-based care and flexible options/occasional care.
  3. Pay Equity – equal opportunity for promotion for women (including part-time workers), longer paid maternity leave, better arrangements for breastfeeding in the workplace, and government monitoring of pay gaps between different industries for various types of work.
  4. Flexible Work Arrangements – opportunities for flexible hours and working arrangements to ensure good work/life balance, job sharing, and fathers able to equally take paternity leave to better share the care of children. Workplaces need a cultural change that increases respect for part-time workers, working mothers and their childcare commitments (without impacting on advancement opportunities).

Speaker: Susan Helyar, Director, ACTCOSS.
The social strategic outcome is for women and girls to equally and fully participate in sustaining their families and communities; and enjoy community inclusion and wellbeing.  The indicators of progress in this area are:
  • recognition of women and girls’ contributions to the community;
  • increased community leadership and decision making opportunities for women and girls;
  • affordable and accessible gender and culturally sensitive services;
  • pathways for women experiencing disadvantage, social exclusion and isolation;
  • addressing violence against women and their children and protection and support for victims.

Susan spoke about problem areas in the ACT including housing, housing, transport, violence against women and girls, and an environment of patriarchy.

Susan asked the forum for suggestions in relation to 2 key social themes. Responses included:
  1. Gender Specialist Services – more birthing options in the ACT (eg. waterbirths at Calvary, more places in the Birth Centre program and a publicly funded home birth program), more services specific to Aboriginal women and better consultation with Aboriginal women for plans such as the Women’s Plan.
  2. The ACT’s Domestic Violence Strategy – more funding for services, better community consultation, and steps to overcome the ‘shame’ barrier for men engaging with services.

Speaker: Gay Williams, Senior Manager, Design Policy, Environment and Sustainable Development Directorate, ACT Government.
The environment strategic outcome is for women and girls to fully participate in planning and sharing a safe, accessible and sustainable city.  The indicators of progress are:
  • available opportunities for women in decisions about urban planning, transport and the environment; and
  • consideration towards female safety, security and accessibility when designing, building and retrofitting public facilities. 

Gay spoke about how urban planning tends to have a masculine focus on objects (roads, cars, buildings, streets) rather than people and their relationships.  She spoke about a need to change the focus, language used, and values driving urban planning to empower the human experience, invite dialogue and ignite the spirit. 

Forum participants were asked for suggestions in relation to 2 key environmental themes. Responses included:
  1. Accessible Transport – safer road cycle lanes (like in Amsterdam with a concrete barrier between), more accessible public transport and parking, more taxis offering a more reliable service, and designated lanes on cycle paths for walkers and cyclists.
  2. Safety Issues – improved lighting, prioritising a few areas as key community focal points, more interaction between the police and community including more localised police services. Greater community participation/ownership of spaces (e.g. by allowing community art, street performances, music, festivals, food stalls etc.) could improve safety.

If you would like to read more, you can access the full plan (PDF, 488KB) or visit the Women ACT website

Gemma O'Loghlin
Consumer Representative

Friday, July 26, 2013

What's in a name? The UCPH Conundrum

As you might already know, the ACT government is currently conducting preliminary planning for the ACT’s new rehabilitation facility which will be constructed on the University of Canberra campus in 2016-2017. Currently, this facility is referred to as the University of Canberra Public Hospital or UCPH for short.

UCPH will be a sub-acute facility dedicated to rehabilitation and related activities. Sub-acute care is specialised care which aims to improve a person's physical and social functioning and quality of life, often after severe accident or illness, or at end of life. Sub-acute care areas include rehabilitation, palliative care, older person's health and mental health.

UCPH will house physiotherapy and other allied health services, including a rehabilitation gym and hydrotherapy pool, among other features and services.  It will also provide sub-acute mental health services. Acute care services such as surgery will not be delivered at UCPH, nor will it have an intensive care unit or an emergency department. Acute services like these will continue to be provided at Calvary Public Hospital and Canberra Hospital.

At HCCA, we’ve been musing on the name “University of Canberra Public Hospital” and what this implies about the facility. We have had feedback from consumers on the name which consistently says that the word “hospital” is misleading, as it indicates very specific things in the mind of the ordinary consumer.  In particular, people think of hospitals as places you go when are sick and require emergency medical care.

Referring to the new rehabilitation facility at the University of Canberra as a “hospital” has the potential to create confusion in the mind of consumers and may create potentially dangerous situations. A consumer who is unaware that UCPH is a sub-acute facility may present there requiring emergency care, only to be told that they will have to be taken by ambulance to Calvary to be treated. 

Similar facilities in other jurisdictions have side-stepped this problem by appropriately naming the service.  HCCA’s Darlene Cox and Kerry Snell recently visited Victoria on a fact-finding mission about rehabilitation facilities, and they noted that none of the facilities they visited were called “hospitals”. Instead, these services were generally called “centres” (such as the McKellar Centre and the Kingston Centre).  Similarly, other rehabilitation facilities which use the term “hospital” have also included “rehabilitation” in the name (such as Lady Davidson Private Rehabilitation Hospital and Westmead Rehabilitation Hospital).

There doesn’t appear to be any reason why the same principle can’t be applied in the ACT.  A couple of alternative names thrown around by consumers during recent discussions include the University of Canberra Rehabilitation Centre, Rehabilitation Hospital or Rehabilitation and Recovery Centre.

If the ACT government wants to persist with using the name “hospital”, it will require them to undertake a concerted project to educate the ACT community about the difference between different levels of care – primary, acute, sub-acute – and to justify the use of the name “hospital” when in the consumer understanding of the word, UCPH isn’t one.  This seems unlikely to be an effective undertaking, given the longstanding failures around informing the ACT community about other Health Infrastructure Projects. 

In order to find out what consumers think about this issue, we’ve created a short survey. We’d really appreciate it if you could take a couple of minutes to share your views.

The survey closes on 23 August 2013 at 5pm.

Friday, July 19, 2013

The role of ACHS – A new consumer representative’s perspective

Fiona Tito Wheatland is the HCCA nominee to the Council of the Australian Council of Health Care Standards (ACHS).  At the ACHS Council Meeting on Thursday 27 June 2013 at the Park Royal Hotel, Sydney Fiona gave this presentation.
Reading through the Constitution of the ACHS as a new member, with external familiarity with your work, I was struck by its importance for all health care consumers.  As a bureaucrat in the early 1990’s and Chair of the Professional Indemnity Review, I researched deeply into how much preventable patient harm had occurred and what could be done about it. This work included the establishment of the Quality in Australian Health CareStudy, which showed a high level of “adverse events” occurring in hospitals (around 16.6%).[1]  
As a carer and health care consumer myself, I saw how ubiquitous human errors were in health care and how variations in care could often not be explained by different patient needs.  I became passionate about addressing these issues.  I worked over the next decade on many projects – including preparing the ACT’s first Patient Safety Action Plan – all designed to ensure better, safer care for health care consumers. 
What I often saw were deeply committed people working hard and philosophically committed to “First, do no harm”, but without effective ways of ensuring or even knowing that this was the lived experience of their patients.  I saw systems which often were remarkably harm tolerant and self-justifying.  I started my PhD studies in 2004, specifically to look at the barriers to adoption of safer care in health.  Every bit of work I have done over the past 20 years on this subject has been informed by seeing the need for patient safety to be the main ethical and policy principle upon which all health care MUST be based.  The current and continuing role of ACHS in the enactment and delivery of this principle is central.
I was refining one of my PhD chapters recently, when I came across the work of ErnestAmory Codman – a US orthopaedic surgeon.  In the 2 decades from 1900, he became increasingly concerned about the quality of health care.  He developed the radical idea that he should follow his patient’s long enough to determine the outcome of their treatment, and if it failed why – he was very thorough and followed patients up annually to look at the long term impact of the treatments[2].  He called this End Result Analysis.  So committed was he to this idea and so unacceptable was it to his colleagues, that he left the Massachusetts General Hospital and started his own private hospital, and in 1916, published the first 5 years End result data on patient treatments at the hospital.  The data collected was very thorough.  He stated in that publication:
The present paper deals with the analysis of the causes of failure and the determination of the degree within which we can control these causes.  We believe that the most difficult step has been taken when the staff of a hospital once agrees to admit and record the lack of perfection in the results of its treatments.  Improvement is then sure to follow, for it often is the error of which we are ignorant that we persist in carrying with us.[3]
This was in 1916 – almost a century ago! He had given a public address to the Philadelphia Academy of Medicine in 1913 as an opening shot in a campaign to create a national effort to standardise hospitals. The address “The Product of a Hospital”[4] is well worth reading today, despite the somewhat archaic terms used.  The main thrust of that speech and the paper produced from it is that no judgments of efficiency about the outputs from or inputs to a hospital can be made without knowing whether the patients were benefited by the treatment provided.   He also said that when he was discussing standardisation in hospitals he was looking at a “general movement toward improving the quality of the products on which hospital funds are expended.  As a rule, standards are raised by stimulating the best – not by whipping the laggards”.  He proposed hospitals publicly reporting on the results of treatment.[5]
Applying these theories to his own field, he developed a Registry of Bone Sarcomas[6], because one of his patients who had been originally diagnosed with rheumatism, in fact was suffering from bone sarcoma.  That patient had died because the correct diagnosis came too late – almost ninety years later, a close friend of mine suffered the same fate.  From his registry, he developed an evidence based diagnostic tool, called the Index Chart of Symptoms.
As might be imagined, his reception among his colleagues at the time was not all that positive – he describes spending many lunch hours in the hospital canteen alone!
I have mentioned his story because it illustrates that the ideas and role of ACHS are not new and remain crucially import and and much remains to be done – but that the work required is often not all that popular in some lunch rooms!  As someone who talks regularly to the “products” about their experiences, I see ACHS’ role as central to achieving better care.  I also believe that there is a need to maintain courage to ensure patient outcomes data collection becomes a universal patient safety and quality tool. 
I can remember arguing on a panel that bench-marking, on its own, could lead to a harm tolerant, complacent system.  The patient safety question wasn’t whether harm was under benchmark, but whether the harm that did occur was preventable.  Dr Peter Collingnon a world-renowned infectious diseases expert, spoke after me about hospital acquired infections rates and he said that he had done just what I was asking for.  The hospital data was under the benchmark, but when they studied the individual cases, 80% were probably preventable on current knowledge.  The ACHS has an important role to play in this area.
Just to add a more positive end to Codman’s story, he was appointed as first chair of the American College of Surgeons Committee for the Standardisation of Hospitals for his work on End Result methods.  This later transformed into the Joint Commission on the Accreditation of Healthcare Organisation (JACHO).  One lesson from Codman may be that there is a difficult balance between having friends and improving the system.  A second lesson is that you may need to take the long term view in judging your success.
Thank you for the opportunity to work with you on this important work.  As a health care consumer, I feel a bit like the story of the difference between between being a farmer and a pig at a BBQ – the farmer is very interested as its his living, the pig is committed!
On a lighter note, my daughter, who had been hearing endlessly about my thesis in a recent visit, sent me a quote on my phone yesterday, and I will conclude my talk with it:
More people would learn from their mistakes, if they weren’t so busy denying them[7].

Additional references relating to Ernest Amory Codman, which you may find interesting:
Berwick D M.  E A Codman and the Rhetoric of Battle: A commentary.  1989 The Milbank Quarterly, volume 67(2), pages 262-267.
Christoffel T.  Medical care evaluation: an old, new idea. 1976 Journal of Medical Education, volume 51, February, pages 83-88.
Codman E A.  The shoulder: rupture of the suprapinatus tendon and other lesions in or about the subacrominal bursa. 1984 R E Kreiger, Malabar (Florida) : The autobiographical preface and the Foreword by Dr A F De Palma provide detailed information about Codman’s life and work.
Crenner C. Organizational reform and professional dissent in the careers of Richard Cabot and Ernest Amory Codman, 1900-1920.  2001 Journal of the History of Medicine and Allied Sciences, volume 56(3) July, pages 211-237.
Donabedian A.  The End Results of Health Care: Ernest Codman’s contribution to Quality Assessment and beyond.  1989 The Milbank Quarterly, volume 67(2), pages 233-256.
Mallon W J.  E Amory Codman – Codman considered father of evidence-based medicine.  2007 AAOS Now (American Academy of Orthopaedic Surgeons), January/February, pages 58-60.
Mallon W J. E Amory Codman, surgeon of the 1990s. 1998 Journal of Shoulder and Elbow Surgery, September/October, pages 529-536.
Mulley A G.  E A Codman and the End Results Idea: A commentary.  1989 The Milbank Quarterly, volume 67(2), pages 257-261.
Reverby S. Stealing the Golden Eggs: Ernest Amory Codman and the science and management of medicine. 1981 Bulletin of the History of Medicine, volume 55(2) Summer, pages 156-171.

[1]               Wilson R McL, Runciman W B, Gibberd R W, Harrison B T, Newby L and Hamilton J D.  The Quality in Australian Health Care Study. Medical Journal of Australia 1995 (6 November) volume 163, pages 458-471.
[2]               For a recent brief discussion of his method, see  Brand, Richard A. Ernest Amory Codman, MD, 1869-1940. 2009, Clinical Orthopaedics and Related Research, volume 467, pages 2763-2765.
[3]               Codman E A. A study in hospital efficiency as demonstrated by the case report of the first five years of a private hospital.  1916  self published – available electronically for purchase through Abebooks.
[4]               Codman E A. The Product of a hospital 1914 Surgery, Gynaecology and Obstetrics; volume 18; pages 491-496.  This article was reprinted in facsimile in 1990 in Archives of Pathology and Laboratory Medicine, volume 114, November; pages 1106 -1111.
[5]               For further information on his work, see Neuhauser D. Ernest Amory Codman MD, 2002 Quality and Safety in Health Care, volume 11; pages 104-105;  and Mallon WJ.  Ernest Amory Codman: The End Result of a Life in Medicine. 2000 W B Saunders Philadelphia.
[6]               McLendon W W. Ernest A.Codman MD (1869-1940), the End Result Idea, and The Product of a Hospital. The challenge of a man ahead of his time and perhaps ours. 1990 Archives of Pathology and Laboratory Medicine, volume 114, November; pages1101-1104: page 1102.
[7]               Quote attributed to Harold J. Smith

Thursday, July 18, 2013

Alzheimer's Australia End of Life Care Survey

Alzheimer’s Australia is conducting research on end of life care for people with dementia.

The project aims to identify barriers and enablers to quality end of life care from the perspective of carers involved in end of life care.

If you are a current or former family carer of a person with dementia, Alzheimer’s Australia wants to hear about your views and experience with end of life care for people with dementia by completing an online survey.

The survey is anonymous and will take no longer than 8 minutes to complete.

The results from this survey will help promote public discussion and debate about complex issues around end of life care.

Please access the survey via the following web link: https://secure.piazzaresearch.com.au/ls2/index.php/478875/lang-en

This survey will close on the 31st of July.

If you have any questions about the project or the survey please contact Kim Taylor via phone on (02) 6278 8922 or by email at kim.taylor@alzheimers.org.au.

Wednesday, July 10, 2013

Noise and vibration from refurbishment work on Level 5, Building 1 at the Canberra Hospital

From the ACT Health Redevelopment Unit:

Level 5 of Building 1 at Canberra Hospital was vacated in the second half of 2012 when various services and functions were transferred to Stage One of the Centenary Hospital for Women and Children. Level 5 is now being refurbished to provide a total of 60 new hospital beds.

The early parts of the refurbishment work will involve grinding old vinyl floor adhesive from the floor. This work will generate some unavoidable noise. All efforts are being made to minimise the disruption wherever possible.

The noisy works will commence on Thursday, 11 July and will continue into August 2013.  Staff, patients and visitors directly above, below and surrounding the site may be affected by the noise and vibration. We apologise for the inconvenience and thank you for your patience.

Staff, patients and visitors are reminded to take care around ACT Health construction sites. Please observe all directional signs, speed limit signs, barricades and direction from traffic controllers during the construction of new ACT Health buildings and infrastructure.

Construction sites are clearly barricaded to prevent entry and can only be accessed by: construction site personnel; pre-arranged deliveries; ACT Health representatives (i.e. Redevelopment Unit); and others that have pre-arranged site visits and/or meetings and have an escort from the appointed construction company project manager at all times (i.e. Workplace Safety, B&I, etc).  Anyone who does not meet the above criteria and who accesses a construction site is putting themselves at risk of harm and potential disciplinary action.

Please Note: Accessing a construction site without permission is a breach of ACT Health Work Health & Safety Policy and the Work Health and Safety legislation and could incur a fine of up to $150,000 and/or a possible jail term for individuals found in breach of this legislation.

For more information, please contact the Redevelopment Unit on 6174 8100 or by email HIP@act.gov.au.