National Blood Authority Transfusion (NBA) Update Melbourne 15 May 2014 By Jo Bothroyd

I attended the day-long Clinical Practice update session of this event as the Consumer Lead on the ACT Standard 7 Blood and Blood Products Committee.  HCCA sponsored my registration.

Most presentations were very well received and focused on projects or programs designed to help health services develop their Transfusion Quality Improvement Systems so that they comply with Standard 7 which requires;

“Clinical leaders and senior managers of a health service organisation implement systems to ensure the safe, appropriate, efficient and effective use of blood and blood products. Clinicians and other members of the workforce use the blood and blood product safety systems.”

and on the accreditation criteria listed at the bottom of the post.*

Both the Australian Red Cross Blood Service and the National Blood Authority have developed of smart phone/IPad applications (apps) to provide information and support for transfusion services. A WA Red Cross Blood Service app designed for services treating people with high iron/ferritin levels was reported as achieving reduced times from referral to treatment and cost savings for health services.  High iron and related conditions are apparently becoming more common because people are living longer and are more readily diagnosed.

Through the NBA app transfusion service can access information about:

1. Use and management of blood and blood products in accordance with national evidence-based guidelines.

2. Risk mitigation, education and safety and quality improvement programs for the management and use of blood and blood products.

3. Reporting and feedback mechanisms into risk management processes for adverse events, incidents and near misses relating to transfusion practice.

4. Policies, procedures and protocols for documenting transfusion details in the patient clinical record.

5.  Appropriate management of blood and blood products.

6. Informed consent is documented for transfusions.

From my point of view development of smart technology apps will provide a new level of immediate access to evidence based information and therefore should reduce delays in determining the best approach to treatment. The alternative up until now (when beside computers were not available) was access to information via a desktop.

A presentation on informed consent revealed that there is no agreed approach to obtaining consent in terms of blood and blood products.  Some services get separate consent for each type of blood product; some services appear to use the general consent signed on admission to hospital as consent for blood and blood products; and some presenters suggested their organisation is considering getting separate consent for each unit of blood or blood product given to a consumer.

My impression was that there is good communication between the NBA and State Based Transfusion Services and between individual State and Territory services.

Participants did say that they valued the opportunity to network and develop links with other services and individual clinicians.

Jo Bothroyd

*Standard 7 four key Accreditation Criteria

Governance and systems for blood and blood products prescribing and clinical use - Health service organisations have systems in place for the safe and appropriate prescribing and clinical use of blood and blood products.

Documenting patient information - The clinical workforce accurately records a patient’s blood and blood product transfusion history and indications for use of blood and blood products.

Managing blood and blood product safety - Health service organisations have systems in place to receive, store, transport and monitor wastage of blood and blood products safely and efficiently.

Communicating with patients and carers - Patients and carers are informed about the risks and benefits of using blood and blood products, and the available alternatives when a plan for treatment is developed.

Innovation in health care - conference report (Part 1)

The Victorian Health care Quality Association committee decided to bring people into one room to share their award winning innovative practice. The papers focused on the acute health sector.

The innovation showcase was an event put on by the Victorian Healthcare Quality Association, the Centre of Research Excellence in Patient Safety, the Victorian Department of Health and the Australasian Association for Quality in Health Care. It was held in St Kilda over two days, and show cased quality improvement initiatives which have won major awards across Australia over the previous 12 months.

The day started with a short introduction by Prof Chris Brook, the Chief Advisor on Innovation, Safety & Quality. He has responsibility for quality and safety in health care and clinical trials in Victoria, no small task. 

He declared that working in quality and safety in health care in not for the faint hearted and went on to give three examples:

In the 1880s Semmelweis noticed that women giving birth at home had a much lower incidence of childbirth fever than those giving birth in the doctor's maternity ward. His investigation discovered that washing hands with an antiseptic solution before a delivery reduced childbed fever fatalities by 90%. He published his findings and was scorned by the medical profession. He died in poverty and misery.

In the 1920s a US surgeon, Codman was concerned that the rate of adverse events is too high and wanted to standardise practice. He developed the grand results idea in which he was focussed on measuring outcomes. And for this he was he was kicked out of Harvard, his hospital, and died in misery.

And finally, Dr Barry Marshall in WA who showed that  peptic ulcers were in fact a result of bacteria and not caused by stress, spicy foods, and too much acid. No one believed him as it would have meant stoping endoscopies! He won a Nobel Prize for his work. His work was incredibly important and changed the world yet he struggled, lost friends along the way...

Prof Brook also challenged participants to describe the notion of quality of health services in a way to make it understandable and meaningful for all parts of the system - for staff, patients and the community. There are lots of words to describe quality – but the more you have the harder it is to get people to commit to them and own them. How do you give ownership to different groups? How do you get clinicians to own the appropriateness and effectiveness of care and for consumers to own the patient engagement?

Dr Cathy Balding Governance for creating great consumer experience and governance for great care.

In the last few years, and particularly with the introduction of the national standards, Dr Cathy Balding has been interested about how to take governance form a thing that people have to do to something the fosters great care. Clinical governance is not something to endure but rather it is something to drive good practice and safe care.

Cathy spoke about the many dimensions of quality care and the complicated approach some organisations take in t developing their safety and quality frameworks and clinical governance structure. She said quite clearly that we spend too much time and energy focussing on the process rather than the end product. Ie, patient centred care, safe care.

There is an important role for maintenance in quality and safety, just like the airline industry. The foundation work is the monitoring of care, ensuring standards are met and that policies are implemented. And as for accreditation, Cathy Balding relayed a story from a colleague in which they likened accreditation to an exam – it is important to pass but it is not a means in itself.

Balding talks about quality governance and develop these systems with concrete purpose and show a concrete relationship between our quality governance systems and quality of care. There is nothing secret about how to create great consumer experiences. Balding refers to Mid Staffordshire as highlighting the key aspects of care. Now in the past year or so there has been lots of discussion and consideration of the findings of the public inquiry into Mid Staffordshire Trust in the NHS (UK), and for good reason. There were significant failings in governance and as a result a failure to deliver good, safe patient care.

Balding emphasised the importance of fostering a common culture shared by everyone in the service of putting the patient first. It is jargon- what does it mean? I agree with her on this. Patient Centred Care sounds good but it is an empty term and so we need to challenge the rhetoric.  For example, that someone who lives on the south coast and has to drive 3 hours away from the outpatients department at a large hospital. They then wait a long time in a crowded waiting room and then given an 8am appointment in month’s time. That happens all too regularly and with little (or no) consideration of what is involved for the consumer in getting there.

Balding also referred to the Picker Institute eight domains of care . We have been suing these in consumer training for many years and they make sense.  

We now have the Standards 1 and 2 so we now know that governance matters. There are five aspects that the standards cover:

•     Governance and quality improvement
•     Clinical practice
•     performance and skills
•     incidents and complaints – reporting and investigation systems, complaints systems and open disclosure
•      patients rights and engagement – charter of healthcare rights, patients as partners, confidentiality, patient feedback

Pillars of quality governance

•      Strategic planning leadership and culture
•      Consumer participation
•      Effective and accountable workforce
•     Compliance good practice risk and improvement

Balding asked the audience: what do you want every one of your consumers and their families to experience every time?

We want care that is responsive to the individual, care that is connected, care that is safe and effective for everyone, every time. And we will be a hospital that supports our staff to deliver this.

And the executive leadership team need to commit to supporting staff and provide for this. We need to hear statements from them like: we will give you direction knowledge resources and support to make this happen.

Balding went on to talk about the framework for quality, safety and the patient experience at Western Health. There are four questions they ask:

•   Were you seen and treated as a person?
•   Did you receive help, treatment and information in a coordinated way
•   Did you feel safe? Were you safe?
•   Did your treatment have the desired effect?

These are great questions and I think more of us need to ask them.

Darlene Cox
Executive Director

What do consumers value?

In a nutshell, what do consumers value in health care?

Well, over the years consumers have told us this:

• spend enough time during my consultation to listen, talk and explain things to me
• explain things to me in a way I can understand
• encourage me to ask questions and does their best to answer them
• give me enough information about my condition
• give me enough information about my treatment options
• include me in decisions about my treatment options
• explain the purpose of tests and treatment in a way that I understand
• explain the results of diagnostic tests in a way that I understand
• support me to self-manage my health

Trial of the use of self-administered Sub-cutaneous Immoglobulin (SCIg) at the Canberra Hospital.

Late in 2013 I attended a presentation about the ACT’s participation in this very significant national program. Current SCIg consumers (who made up the bulk of the audience), were enthusiastic about the introduction of SCIg.  I attended as Health Care Consumers ACT (HCCA) Consumer Lead on the Standard 7 Committee (Blood and Blood Products). 

Ann Gardulf RN (Registered Nurse) Phd, who gave the presentation is from the Swedish Kaolinska Institute.  She published the results of her trials of the use of self-administered home-based SCIg in 1991. Apparently most Nordic countries, Germany, France and England now offer this service to SCIg users.

Consumers on the trial will be able to self-administer the SCIg at home rather than attending Canberra Hospital each month. They will attend an education program, have ready access to the team at Canberra Hospital and their outcomes will be monitored.  

The advantages of home based self-administered SCIg are many including:

• Home-based SCIg users report that they feel better because they have one small dose each week in contrast to hospital-based consumers who get the full dose in one monthly injection;
• Home-based SCIg users’ quality of life will be improved because they will have fewer interruptions to school, work or other activities; and
•  Use of home-based SCIg will reduce the cost of providing this treatment to consumers.

If you would like to express an interest in switching SCIg, or finding out more about the program contact Anastasia Wilson, SCIg Nurse at Canberra Hospital. 

Email: anastasia.wilson@act.gov.au

Phone: 02 6244 3272

Jo Bothroyd

HCCA Consumer Representative

11 February 2014

HCCA response to the ACT Budget 2014

The ACT Government is to be commended for putting people first in this budget.  They have taken the decision to absorb the cuts made by the Federal Government and have crafted a budget that delivers modest expansion of health services.

ACT Budget Papers

The ACT Government have taken the decision to absorb the cuts announced in the recent Federal Budget.  These cuts are by no means small. Treasurer Barr today outlined that more than $500m has been written off the ACT income from 2014-15 until 2017-18. This is due to a downturn in the housing market which will result in less land being sold for development ($250m over four years) and also the Federal Government walking away from the National Health Reform Agreements ($248m over four years).

The Treasurer outlined that the Commonwealth is not only the major employer in the Territory but is also a large consumer of goods and services. The cuts announced in the Federal Budget will see between 6000 and 6500 full time jobs disappear (2.9% of employment in the ACT). This will have flow on effects to the Canberra economy.

The Treasurer stressed that unlike other jurisdictions, including the Commonwealth, the ACT Government does not borrow money to fund recurrent operating expenses and that they run a cash surplus every year.  They only borrow for infrastructure projects that add to the asset base of the Territory. And this budget does contain infrastructure spending for the health sector.

This budget has allocated funds for more general inpatient beds at both Canberra and Calvary Hospitals (15 beds). The 31 beds announced at Canberra Hospital includes 15 beds that were funded in 2013-14. This is welcome news. We continue to see more people presenting at the Emergency Department requiring admission and Canberra Hospital has been under significant pressure, routinely operating at over 90% capacity. There is also provision for additional staff at Canberra Hospital to support the opening of these beds which is good news, as you can’t open beds without having staff in place.

Hospital in the Home (HITH) which looks at caring for inpatients in their home will also have the service increased by six ‘beds’.

There is also funding to support two new emergency department physicians one for Canberra Hospital and one for Calvary. This is hoped to decrease waiting time in emergency.

The Walk in Centres are a great addition to our health system and provide affordable, appropriate care to consumers. This budget allocates funds for the operation of a new Walk in Centre at the Belconnen Health Centre.

There is also an announcement of about $9m for the expansion of outpatient services including a focus on chronic pain management. People living with persistent and chronic pain are not serviced well by our existing services and this allocation will make a difference.

There is also a modest increase to delivering intensive care at both public hospitals with two more beds at Canberra Hospital and another bed at Calvary Public Hospital. Canberra Hospital is the tertiary referral hospital for Canberra and the Capital Region and this will go some way to meeting the ongoing demand for these important services.

Calvary Health Care ACT will receive ongoing funding of $1.5m for the Birth Centre to continue. This is welcome news as the Birth Centre complements the Canberra Midwifery Program that runs at the Centenary Hospital for Women and Children in Garran.

This follows the launch of the Obesity Management Services, which is a community based service to support people with a BMI of more than 40. An extension of this program is the provision of publically funded bariatric surgery. This amounts to just over $1m over four years and modelling suggests this will enable thirteen people to have the surgery each year. This will make a significant difference to their lives and complement the important work of the Obesity Management Service.

We will see the opening of the Capital Region Cancer Service early in the new financial year. The opening of this services has been delayed due to a burst water pipe, but work has almost finished to rectify this and we see $8.5m made available to deliver services.  Provision has also been made for an expansion of the lymphedema services at Calvary Hospital, with $1.9m funding over four years and new three staff positions to support this.  This service is important in supporting people, mostly women, in overcoming the effects of breast cancer and other conditions affecting the lymphatic system.

Mental Health funding has been maintained with an emphasis on community programs for suicide prevention, and children and youth mental health. Suicide prevention funding will include bereavement counselling for those who have lost someone due to suicide and community awareness campaigns. There has been provision for a modest expansion of service for people with eating disorders. This is an area of need in our community and we welcome the investment in this.

The Funding for the Health Infrastructure Program has been continued and HCCA is excited to see the commitment to the University of Canberra Public Hospital. We look forward to continuing to work with the Government on these projects.

In stressful times it is hard to get the balance right but on this occasion I think the ACT Government has done well in the short term to compensate the Canberra community from the worst effects of the Federal Budget. The big question is how can we sustain this into the future?

Darlene Cox

Executive Director

@darlenecox