Vic intern blog

Quality improvement: an international perspective

Author: Lachlan Crowe

Date: 14 March, 2018

Quality improvement (QI) in health has increasingly become a priority following a number of serious adverse events in health settings both locally and abroad. To avoid similar situations occurring again, health services have responded by working to build a culture of improvement and innovation using a QI lens. Having recently returned from working in the health improvement sector in the British National Health Service (NHS), I have been struck by the similarities between the UK and Victorian health contexts in this respect. 

The UK context

‘Place the quality and safety of patient care above all other aims for the NHS.’ (Berwick, 2013)

In the UK, an independent public inquiry into the Mid Staffordshire NHS Foundation Trust commenced in 2010, chaired by Sir Robert Francis QC. The completed report, published in 2013, identified significant failings in the health service that resulted in poor patient care and outcomes. Following this inquiry, Dr Don Berwick, a leading international expert on health quality and improvement, was tasked with conducting a review of patient safety in the NHS on behalf of then Prime Minister David Cameron. In his review Berwick identified the factors that had led to the events of Mid Staffordshire, and made a number of recommendations of reform for the system. Berwick’s review, A promise to learn - a commitment to act: improving the safety of patients in England, commonly referred to as the ‘Berwick report’, set a vision for the NHS to become a learning organisation that continuously improves to achieve quality patient care and outcomes. Actions subsequent to this review included the establishment of NHS Improving Quality (now NHS Improvement) and an increased organisational focus on safety and quality improvement.

The Victorian context

‘Safety and quality improvement must be a core goal of the department and health system.’  (Duckett, Cuddihy, & Newnham, 2016)

In Victoria, a number of perinatal deaths at Djerriwarrh Health Service came to light in early 2015. These were investigated in a report published in 2015 for the Victorian Department of Health and Human Services by senior obstetrician Professor Euan Wallace. Following this report, a panel chaired by Dr Stephen Duckett, Director, Health Program at the Grattan Institute, was commissioned by the Minister for Health to review hospital safety and quality assurance in the state. This review, Targeting zero: Supporting the Victorian hospital system to eliminate avoidable harm and strengthen quality of care, is often referred to as the ‘Duckett report’ and has driven many subsequent initiatives and set the priorities for improving the safety and quality of care for all patients in Victoria. This included the establishment of Safer Care Victoria, the peak state authority for leading quality and safety improvement in healthcare.

The similarities

‘…in all modern health systems, patients frequently suffer avoidable harm while receiving care. No one should accept avoidable harm as an inevitable and ineradicable feature of healthcare…’ (Duckett, Cuddihy, & Newnham, 2016)

The similarities in sequence of events and inquiries, and the parallels in the findings of these investigations are clear. In both contexts, significant negative events were uncovered and necessitated a comprehensive investigation and review of practices. In both contexts inadequate oversight and governance combined with cultural failings with tragic effect. While there are undoubtedly notable differences between the two environments most obviously in the structures and scale of health organisations, as well as other local factors, common key learnings can nevertheless be drawn.

The implications

‘It is the responsibility of everyone working in the health system – from the Minister through to the people working at the frontlines of care – to understand and learn from the tragedy at Djerriwarrh Health Services.’ (Duckett, Cuddihy, & Newnham, 2016)

When these kinds of events occur, our challenge is how we respond and prevent them from happening again. We need to improve. As a health care sector we need to continually assess and challenge the delivery of service, and seek to do better.

All of this must happen in a context of tightening budgets. Better Care Victoria (2018) notes that ‘demand for public hospitals will continue to increase at a faster rate than funding for additional capacity’. Similarly, in the UK the Five year forward view (2014) identified the need for the NHS to deliver £22 billion worth of efficiency savings by 2020-21 to continue to meet rising service demand. Just improving care isn’t enough. To do the same thing better will improve outcomes, but will not meet the increasing demand facing the system. To meet this challenge, we need to innovate, to find new and creative ways of working, and to embed these into organisational culture.

To develop a culture of improvement and innovation, everyone needs to be involved. There must be support and action from top level management and government, through to clinicians and local support staff. A culture of transparency, and a focus on continually learning allows adverse events and near misses to become impetus for improvement. Importantly there needs to be a collaborative approach to this process. The sharing of learnings within and across organisations is crucial as we aim for all people to have access to the best possible care and to achieve their best possible health.

The future

‘In the end, culture will trump rules, standards and control strategies every single time, and achieving a vastly safer NHS will depend far more on major cultural change than on a new regulatory regime.’ (Berwick, 2013)

In both the UK and Victoria, significant reform has been made to the oversight and governance around health services. At a local level, clinicians, QI departments and teams are developing and implementing new initiatives to better deliver health services to the community. The effectiveness of building a collaborative, learning, improving and innovating culture will ultimately define the success of these initiatives.

This environment and context makes for a challenging, interesting future ahead for the health industry. We need to do things differently. I look forward to being part of the change.

References

Berwick, D. (2013). A promise to learn–a commitment to act: improving the safety of patients in England. London: Department of Health.

Bettercare.vic.gov.au. (2018). Background. Available at: https://www.bettercare.vic.gov.au/about/background

Duckett, S., Cuddihy, M., & Newnham, H. (2016). Targeting zero: Supporting the Victorian hospital system to eliminate avoidable harm and strengthen quality of care. Report of the Review of Hospital Safety and Quality Assurance in Victoria. Melbourne: Victorian Government.

NHS England (2014). Five year forward view.

Francis, R. (2013). Report of the Mid Staffordshire NHS Foundation Trust public inquiry: executive summary. London: The Stationery Office.

Wallace, E. M. (2015). Report of an Investigation into Perinatal Outcomes at Djerriwarrh Health Services.