ACT Health - Partnering with Consumers

Last week ACT Health underwent accreditation against the new national standards.

I was invited to speak at the opening meeting with the surveyors. My speaking notes are posted here for the information. Throughout the week we had the opportunity to speak with the surveyors in more details about the work of the Health Directorate and staff at Canberra Hospital and Health Services about how they partner with consumers at three levels, as patient, consumers and as citizens.

Darlene Cox
Executive Director

The Health Care Consumers’ Association is the longest running health consumer group in Australia. We receive funding from ACT Health to train and support consumer representatives and to provide consumer perspectives on policy and operational matters.

We do not have Consumer Advisory Committees like other health services. Consumer and carer representatives and consumer organisations are heavily embedded in ACT Health and health services. The consumer voice is heard across all levels of the health service - as patients and carers, as consumer representatives, through consultation with consumer groups and the broader community.
HCCA supports more than 50 consumer representatives who are participating in over 100 committees across ACT Health. There are also more than Mental Health Consumer Reps and Carer Reps.

We run training sessions 3 times a year to recruit new members of the community who are interested in becoming involved. I want to touch on a few of our achievements.

Consumer representation has been a constant through quality and safety processes and clinical governance.

We have had a consumer representative on the Canberra Hospital Clinical Review Committee for almost ten years which is significant.

We also have consumer reps on the Interagency Clinical Review Committee, Quality and Safety Committees, Clinical Ethics Committee, Awards Panels, and the Medical and Dental Appointments Committee.

The consumer perspective is also valued in the corporate governance with consumer representatives on the Executive Directors Council, and Executive Council as well as the Local Hospital Network Council.

We also have consumers as members of selection panels for senior staff, including Clinical Directors, the Deputy Director General and Director General positions, a well-established indicator that an organisation has a culture of consumer centred care.
Consultation with consumers and carers is embedded in the policy development and review processes.

We also have significant involvement of consumers in the Health Infrastructure Program with active involvement of consumers in User Groups and project management committees. There is also consumer and community consultation to inform the designs and models of care. There are consumer representatives in the governance committees for HIP, so consumer voices are part of the strategic discussions and decisions.

Since the introduction of the national standards we have had Consumer Leads. This is a group of experienced and well connected consumer representative who take on a leadership role. We are very proud of this model and it reflects the commitment of ACT Health to partnering with consumers.

This year the Consumer Leads are participating in the ACT Leadership Network, a welcome development and builds on the involvement of consumers in training of ACT health staff.

We have built strong relationships and have a good working model of participation that works for us.
We have enthusiasm and commitment to continue to improve the way in which the consumer voice shapes the services for our community so that we have health services that are safety and consistently of a high quality.

Conference Report Community Health: Making Accreditation Work for You By Sue Schreiner

Community Health: Making Accreditation Work for You  July-December 2014

Workshop held 26 September at Canberra Hospital

The workshop went from 9am-4pm with half hour lunch break.

There were 16 participants - all from Community Health (except me).

The presenter was Sue Gilham whose background is in nursing but who now is a Surveyor with The Australian Council on Healthcare Standards(ACHS).  She trains other Surveyors and has been involved in training hospitals in India, Asia the Middle East and Ireland in how to reach accreditation standards.

ACHS is one of 13 bodies whose  business is accrediting health entities’ compliance with National Safety and Quality Health Service Standards(NSQHS) and accreditation. It has a number of Surveyors, including a Surveyor who is a consumer. This organisation is the one chosen by ACT Health. Services to be accredited can choose whoever they wish and significantly, the accrediting bodies do not operate in the same way- so that what one finds acceptable another may not.

The purpose of the workshop was to explain what the Surveyors employed by ACHS expected and would be looking for when deciding accreditation of Community Services provided by Community Health - in particular looking at how Community Health could and should  comply with the Standards. Safety and quality of care for the patient is paramount. The standards and principles which apply to Acute health services also apply to Community health. The measures are the same. There is close scrutiny of claims about how the standards are met - “we look at the clinical content of the record and its quality”.

NSQHS standards consist of 10 Standards and 41 Criteria (209 Core actions and 47 developmental actions)   

Basically what the Surveyors are looking for is how the Standards are met by the organisation (ACT Health) as a whole and by each of the services. The Standards will be surveyed “by discussions with all groups. Reviews of policy and related documents,committee and departmental minutes,mandatory audits and reviews, active use of the findings, communication to senior level and to clinical teams, review complaints,clinical handovers and feedback both positive and negative; visits to community sites, talk to managers and staff members about their outcomes of care, review the clinical indicator reports; review client records for the use of screening and assessment tools. documentation of care plans and intervention, evidence of the engagement of clients in planning care.”

We went through in small groups what 3 of the Standards required. Services are required to prove how they comply with each Standard.  There was much discussion as to what constitutes proof. e.g. policies and procedures,clinical performance indicators, copies of internal and external audits contracts, department and committee quality activities staff training records, feedback and communication,keeping minutes, written records of activity, patient satisfaction surveys.

In greater detail for example against" NSQHS 1 (Governance for safety and quality in health service organisations was : “Measure of patient experience of admitted overnight patients - there could be a list of mechanisms such as surveys,interviews or focus groups used to seek feedback about experiences from admitted overnight patients where feedback is monitored within the organisation’s governance system”.

“Other Performance Measures” were complaints,incidents, near misses, safety assessments, patient satisfaction surveys.”

“Surveyor Verification” consists of; 

1. examining evidence demonstrating how the service has achieved the standards and how they have been incorporated into everyday practice
2. Interviews-staff, client focus groups, service providers, consumers, stakeholders
3. observation
4. review documentation

This is an attempt to summarise the workshop, some of it taken from powerpoint slides. Written material was given to participants and is available if you would like it.

The main points from my perspective are that Community care is judged in the same way as Acute care and that there is close scrutiny of each stage of the accreditation.It is all spelled out and available and gives Community Health clear guidelines as to what is expected. If these guidelines are followed the consumer will be well cared for.

Sue Schreiner 

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