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

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