1. Clinician-led quality and safety improvement Converting the vision into reality Ian Scott Director of Internal Medicine and Clinical Epidemiology Princess Alexandra Hospital Associate Professor of Medicine University of Queensland Brisbane Hunter New England Quality Exposition Tamworth 16/9/10

2. Quality and safety improvement Aims –To provide safe, effective, efficient, appropriate, responsive, timely, patient-centred care –To provide care at the right time to the right person in the right manner –To maximise the comfort, dignity and health of a patient’s journey through the healthcare system Which is more successful? –Clinician-led vs managerially-led Q+S improvement 3 elements of Q+S improvement –Capacity: workforce, infrastructure, skill set –Processes: models of care –Outcomes: clinical and non-clinical In-hospital care Ambulatory care Generic principles

3. In-hospital care Initial evaluation Diagnostic work-up Clinical stabilisation Formulation of care plans Disposition decisions Execution of care plans Completion of comprehensive assessments Management of background medical problems Avoidance of complications Patient/carer education Recovery/rehabilitation Disposition decisions Acute In-patient Peri-discharge Transition to community care Preparation for discharge Post-discharge follow-up Community-based care services and support Communication to care providers Diagnosis and treatment of acute problem(s) Optimisation of function and physiology Enabling smooth transition to community care + preventing readmission

4. Proposed service principles Patient perspective PrinciplesPractices What is wrong with me? Prompt evaluation and diagnosis Access to diagnostic investigations Early senior clinician review Early risk assessment Interdisciplinary communication Who is looking after me? Continuity of careConsistent interdisciplinary team throughout acute admission Systems for clinical handover Can you make me better? (Am I in good hands??) Effective management of symptoms, primary pathology and co- morbidities impacting on health Early senior clinician review Care guidelines and pathways Systems for continuing education Systems for audit of processes and outcomes Will it hurt?Minimising adverse effects of hospitalisation Early risk assessment for common complications linked to care plan Regular interdisciplinary communication Safe medication practices Systems to reduce functional, nutritional, cognitive decline QH Statewide General Medicine Clinical Network 2010

5. Proposed service principles Patient perspective PrinciplesPractices Will I get back on my feet? Early functional rehabilitation Consistent interdisciplinary team with a team focus on early mobility and independence What are my (our) options? Involve patients (and family/carers) in decision making Patient-carer counselling and education When will I be able to go home? Define discharge expectations Effective discharge planning What should I do now? What will I do if things go wrong again? Effective handover Appropriate follow-up Patient education and self-management Effective transitional care (eg discharge communication; patient-held information; medication reconciliation; red flags) Systems for following up high risk patients with interventions as required QH Statewide General Medicine Clinical Network 2010

6. In-hospital care Initial evaluation Diagnostic work-up Clinical stabilisation Formulation of care plans Disposition decisions Acute In-patient Peri-discharge Diagnosis and treatment of acute problem(s)

7. Medical assessment and planning units Transferring patients from ED to more suitable medical environment, reducing ED overcrowding Higher level monitoring for more acutely ill patients Cohorting of acute medical patients after-hours Early multidisciplinary assessment Identification and discharge of short-stay patients

8. Evidence for acute medical units Peer review literature No controlled trials Nine before-after analyses of 7 units in UK and Ireland Two studies, one prospective, reported significant reductions in in-patient mortality of between 0.6 and 5.6 percentage points Four studies reported significant reductions in LOS: 1.5 to 2.5 d One study reported 30% decrease in waiting times for patient transfer from ED to medical beds Two studies described significant improvements in patient and staff satisfaction with care Three studies saw the proportion of medical patients discharged directly home from AMU increase by 8 to 25 percentage points Three studies noted no increase in 30-day readmission rates following unit commencement Grey literature Eight non-peer-reviewed reports relating to 48 units confirmed reductions in length of stay. Scott, Vaughan, Bell Int J Qual Health Care 2009

9. Plethora of variants Acute medical assessment unit (AMAU) Medical assessment and planning units (MAPU) Acute assessment unit (AAU) Acute medical wards (AMW) Acute planning units (APU) Rapid assessment medical units (RAMU) Rapid assessment and planning units (RAPU) Early assessment medical units (EMU) Observation medicine units (OMU) Short stay medicine units (SSMU) Surgical assessment and planning units (SAPU)

10. Integrated hospital emergency care Reconfiguration of EDs into several different functional areas –high acuity/high complexity (or critical care areas) –low acuity/low complexity patients (observation bays) –low to medium acuity/high complexity patients Co-location of medical assessment and planning units (MAPUs) with EDs –low to medium acuity/high complexity patients –Aim to discharge or transfer patients with 24 to 48 hours –Daily, consultant-led ward rounds, early multidisciplinary assessment, and prioritised access to ancillary services Admission avoidance and rapid response community teams within EDs –Screen, identify and provide community care for patients who do not need inpatient care Multi-purpose short stay wards adjacent to ED –For fully assessed and medically stable patients undergoing treatments or procedures prior to discharge within 24 hours. Dedicated emergency surgical teams –Exclusively on call to assess and organise emergency surgery for ED patients Patient pull strategies by receiving units Streamlined assessment and admission processes Optimal use of transit and discharge lounges

11. Integrated hospital emergency care Results of redesigned emergency care systems: –16% decrease in acute medical admissions –4% decrease in acute surgical admissions 1 Australian experiments involving 60 acute hospitals in NSW and Flinders Medical Centre in Adelaide: decreases in ED access block 2 1.Boyle et al. Emerg Med J 2008; 25: 78-82. 2.O’Connell et al. Med J Aust 2008; 188 (5 Suppl): S9-S13.

12. Integrated hospital emergency care Scott IA, Wills R, Watson M, et al Qual Saf Health Care 2010 (under review)

13. In-hospital care Acute In-patient Peri-discharge Optimisation of function and physiology Older patients with complex needs High prevalence of cognitive impairment, physical dependency, social isolation At risk for hospital-acquired complications (delirium, falls, polypharmacy, immobilisation) Need for high functioning multidisciplinary teams Need for patient/carer/family education and support

14. In-hospital quality and safety issues Behal & Finn Acad Med 2009; 84: 1657-1662 16 hospitals Issues raised on reviewing deaths 2002-2007

15. Failure to rescue Strong consistent correlation between risk- adjusted failure to rescue rates and risk-adjusted in- hospital mortality rates for all 6 conditions –AMI, CHF, pneumonia, stroke, GI haemorrhage, hip fracture R = 0.20-0.38; p<0.01 Hospitals with best failure to rescue rates had between 22% and 31% lower relative mortality rates across all 6 conditions compared to hospitals with worse rates 4504 US hospitals 2003 PSI data Isaac et al JGIM 2008; 23: 1373-8

16. Clinical care processes Track and trigger systems and rescue responses for deteriorating patients Hand hygiene/barrier nursing/infection control systems Clinical handover systems/continuity of care Interdisciplinary communication and teamwork Evidence-based process of care packages (‘care bundles’) for specific diagnoses –AMI, CHF, COPD, stroke, sepsis –Hip surgery, PCI, CABG, vascular surgery Prophylactic measures –Catheter-associated bacteraemias –Surgical site infections –Ventilator-associated pneumonia –Falls and pressure areas –DVT/PTE Medication reconciliation/medication safety practices WHO surgery checklist Infection control systems Palliative care service Post-operative care Family/carer communication Post-death debriefing

17. Clinical care processes Comprehensive assessment of patient risks and proactive prophylactic intervention High-risk patient care areas –Patients at high risk of falls, pressure sores, delirium, behavioural problems Regular MDT meetings using patient journey boards Daily morning ward rounds by medical teams Team-based nursing care at the bedside Fast-track access to comprehensive geriatric assessment teams, ACAT teams, other gate-keepers Same day consultant responses for inter-specialty requests for advice on acute management

18. Effects of diagnosis-specific care bundles on HSMR Implementation of eight diagnosis- specific care bundles Central venous catheter/line asepsis Diarrhoea and vomiting Stroke Ventilator acquired pneumonia MRSA infection Heart failure Surgical site infections COPD HSMR of 13 diagnoses reflecting care bundles

19. Effects on mortality Behal & Finn Acad Med 2009; 84: 1657-1662 Physician led improvement teams Early goal-directed treatment of sepsis Central line and ventilator bundles to prevent infections Rapid response teams Standardised care protocols for cardiac surgery, stroke, etc Patient safety programs including clinical handover Feedback to transferring hospitals Improved clinical documentation and coding Increased resourcing: nurse levels ICU, defibrillators, intensivists Hospice-in-the-hospital program Senior managerial work rounds Greater than average decrease seen for all US hospitals Observed total mortality dropped as well as risk-adjusted index

23. In-hospital general medicine services Acute In-patient Peri-discharge Transition to community care Preparation for discharge Post-discharge follow-up Community-based care services and support Communication to care providers Enabling smooth transition to community care + preventing early readmission

24. Readmissions a common problem 3% to 11% all discharges readmitted within 30 days 1 –90% unplanned –80% relate to an acute medical complication –60% occur in patients >65 years age Highest readmission rates in US 2 –Heart failure12.5% –Pneumonia9.5% –PTCA10.0% –COPD10.7% –Other vascular11.7% –CABG13.5% –AMI13.4% 1.Jencks et al N Engl J Med 2009 2. MedPAC, “Report to Congress: Promoting Greater Effi ciency in Medicare,” June 2007; U.S. Department of Health and Human Services, “Hospital Compare,” available at: http://www.hospitalcompare.hhs.gov, accessed September 5, 2009; MedPAC June 2007; Cardiovascular Roundtable interviews and analysis.

25. Patient predictors OR –Age ≥ 80 yrs1.8 –Previous admission <30 dys2.3 –≥5 co-morbidities2.6 –History of depression3.2 –Living alone –Cognitive impairment –Functional status –Nutritional status –Disease severity –Longer index LOS –Lack of health insurance –Residential care –Previous readmissions –Non-adherence Marcantonio et al Am J Med 1999 Older patient cohort ≥60 yrs Thomas & Holloway Med Care 1991 Sullivan J Am Geriatr Soc 1992 Librero et al J Clin Epidemiol 1999 Fethke et al Med Care 1986 Corrigan & Martin Health Serv Res 1992 Smith et al J Clin Epidemiol 2000 Au et al Ann Acad Med Singapore 2002 Silverstein et al Proc (Bayl Univ Med Cent) 2008

26. Predicting patients most at risk of readmission Several attempts at risk prediction models in general acute medical patients Most are not very discriminatory –AUROC 0.61-0.70 –Smith et al J Clin Epidemiol 2000 –Billings et al BMJ 2006 –Bottle et al J R Soc Med 2006 –Howell et al BMC Health Serv Res 2009 –Hasan et al JGIM 2009 –Novotny et al Nurs Res 2008 Disease-specific risk prediction models –Congestive heart failure: AUROC 0.60 –Ross et al Arch Intern Med 2008 Accurate model (AUROC 0.83) –requires detailed data on co-morbidities and functional capacity - 20 variables Coleman et al Health Serv Res 2004

27. How preventable are readmissions? 9% to 48% in 7 studies published to 1998 –Median 16% »Benbasset et al Arch Intern Med 2000 5.5% of 437 readmissions JHH »Miles, Lowe J Qual Clin Pract 1999 19% of 363 to one Spanish hospital »Jimenez-Puente et al Int J Technol Assess Health Care 2004 27% of 390 to 12 US hospitals »Halforn et al Med Care 2006 34% of 204 to PAH »Scott et al 2001 (unpublished) 33% of 271 to Israeli hospital » Balla et al Medicine 2008

28. How preventable are readmissions? In one study of general medicine patients 33% readmissions vs 6% controls had quality of care problems –Age and sex adjusted only –Main errors incomplete evaluation (33%) too short hospital stay (31%) inappropriate medication (44%) diagnostic error (16%) –Most preventable readmissions involved CV event or CHF –Mean time to readmission: 10 days –Inpatient mortality 6.7% vs 1.7% among readmissions with no QOC problems (p=0.05) Balla et al Medicine 2008; 87: 294-300

29. How preventable are readmissions? Avoidable complications of care47% Drug-related adverse events13% Erroneous diagnosis/inappropriate care11% Premature discharge20% Poor discharge preparation 9% Halforn et al Med Care 2006

30. Reducing readmissions Discharge planning/preparation Screening for high-risk patients in need of more post-discharge support Multidisciplinary discharge rounds, case conferences Discharge planning protocols and checklists Discharge care plans Patient-carer educational interventions Liaison nurses, discharge co-ordinators, case managers Pharmacist-facilitated discharge program GP input into discharge planning Nurse-led intermediate care units Patient/carer self-management Advanced care plans Discharge support/aftercare Augmented hospital-primary care communication Post-discharge home visits Post-discharge telephonic contact Post-discharge community support Hospital avoidance programs Hospital in the home Chronic disease management programs Scott Aust Health Rev 2010 (in press)

31. Discharge planning Cochrane review updated Jan 2010 Discharge planning defined as: –Inpatient assessment and preparation of discharge plan based on individual needs Multidisciplinary assessment involving patient and family Communication between relevant professionals within hospital –Implementation of discharge plan –Monitoring For elderly patients with medical condition (usually heart failure) readmission rate at 4 weeks reduced by 15% OR = 0.85 (0.74-0.97) Shepperd et al 2010

32. Comprehensive discharge planning and post-discharge support RCT; 363 patients ≥65 years (mean age 75 years) Specialist nurse-led assessment, discharge planning, patient-carer education; written care plans and medication lists; discharge summaries; co-ordination of post-discharge services; home visits (24 hrs and 7-10 days), telephonic follow-up Results at 6 months: –Readmissions: 20% vs 37% p<0.001 –Health costs:$0.6m vs $1.2m p<0.001 –No effects on mortality, functional status, patient/carer satisfaction Naylor et al JAMA 1999

33. Comprehensive discharge planning and post-discharge support Meta-analysis of 18 RCT; 3304 patients with CHF; mean age ≥70 yrs Intervention components –Specialist nurse or clinical pharmacist-led review –Patient education and self-management strategies –Discharge planning –Written care plans and medication lists –Home visits, telephonic follow-up, early clinic review –Enhanced communication between providers Results at 8 months: –Readmissions: 35% vs 43%RR=0.75 (0.64-0.88) –All-cause mortality:14% vs 17%RR=0.87 (0.73-1.03) –% increase QOL score:26% vs 14%p=0.01 –Health care costs: No difference Phillips et al JAMA 2004

34. Comprehensive discharge planning and post-discharge support Transition coaching Self-management tuition in medication use, relapse recognition, personal health record, timely follow with GPs and specialists –Lower readmission rates at 30 days - 8% vs 12%; p=0.05 at 90 days - 17% vs 23%, p=0.04 –Coleman et al Arch Intern Med 2006

35. Comprehensive discharge planning and post-discharge support Comprehensive nursing and physiotherapy assessment Nurse-led education and self-management strategies Individualised program of exercise strategies Written guidelines for post-discharge care Arrangement of community services and social support Nurse-conducted home visit and telephone follow-up commencing in hospital and continuing for 24 weeks after discharge High risk elderly cohort At 6 months: –Fewer readmissions - 22% vs 47%; p=0.007 Courtney et al J Am Geriatr Soc 2009; 57: 395-402.

36. Improving peri-discharge processes A nurse discharge advocate worked with patients during their hospital stay to: arrange follow-up appointments confirm medication reconciliation conduct patient education with individualized instruction booklet that was sent to their primary care doctor Clinical pharmacist called patients 2 to 4 days after discharge to reinforce the discharge plan and review medications Jack et al Ann Intern Med 2009; 150: 178-187

37. Improving peri-discharge processes Jack et al Ann Intern Med 2009; 150: 178-187

38. Improved peri-discharge processes Transition from hospital to home

39. Ambulatory care Review of recently discharged patients Assessment of priority new patient referrals Secondary and tertiary prevention Optimisation of disease control, symptom relief, functional capacity Avoidance of hospitalisation Holistic care for multi-system disease Primary/secondary care collaboration Hospital-based clinics Chronic disease managementEnd-of-life care Palliative care Advanced care planning Acute care in RACF Avoidance of hospitalisation Timely access to specialist review Optimisation of function and physiology Compassionate and appropriate care at end of life

40. Proposed service principles Patient perspectivePrinciplesPractices What do I need to do to stay well? How will I know if my health is deteriorating? Self- management Education in disease patterns and early warning signs and symptoms of disease relapse or loss of control Education in how to self-manage disease Patient-held diaries, self-management tools Who is responsible for my continuing care? Continuity of care Consistent team of GP, specialist, and community multidisciplinary team Systems for monitoring patient progress; recall/reminder Systems for ensuring interdisciplinary communication What should I do if I get worse? Effective early intervention for episodes of disease relapse or decompensation Timely access to specialist review (rapid access clinics), intensified multidisciplinary support, community health services Systems for auditing processes and outcomes QH Statewide General Medicine Clinical Network 2010

41. Proposed service principles Patient perspectivePrinciplesPractices How much burden, inconvenience and potential harm will the management of my health problems impose on me (and my family)? Minimising adverse effects of chronic care Itemised care plans and linked services Education in financial and logistical assistance Safe medication practices Timely access to crisis and respite support What does the future hold for me? Accurate prognostication Risk prediction tools Patient education and reconciliation of expectations How do I best plan for the future? Care planningChronic care plans Advance care planning, advanced care directives QH Statewide General Medicine Clinical Network 2010

42. Ambulatory care Review of recently discharged patients Assessment of priority new patient referrals Hospital-based clinics Chronic disease managementEnd-of-life care Timely access to specialist review Improving referrals from GP to specialist Generally effective strategies included dissemination of guidelines with structured referral sheets (four out of five studies) and involvement of consultants in educational activities (two out of three studies). The effects of 'in-house' second opinion and other intermediate primary care based alternatives to outpatient referral appear promising. Akbari et al Cochrane Database Syst Rev 2008

43. Ambulatory care Hospital-based clinics Chronic disease management End-of-life care Optimisation of function and physiology Intervention designed to manage or prevent a chronic condition using a systematic, evidence-based approach to care and potentially employing multiple treatment modalities Weingarten et al 2002

44. Chronic disease management

45. Gwadry-Sridhar FH, Archives of Internal Medicine, 2004, 164: 2315-2320 Gonseth J, et al., European Heart Journal, 2005, 26(3): 314-315 Holland R, et al., Heart, 2005, 91: 899-906 Roccaforte R, et al., European Journal of Heart Failure, 2005 7(7): 1133-1144 Taylor SJ, et al., Cochrane Database of Systematic Reviews, 2005, 2 Clark RA, et al., British Medical Journal, 2007, 334(7600): 942

46. Chronic disease management Respiratory rehabilitation programs for patients with recent exacerbations of COPD reduce admission rates by up to 87% 1 Improve diabetes control; no evidence yet on complications 2 CDM items and team care arrangements in primary care have not been as effective as expected 3 1. Puhan M, Scharplatz M, Troosters T, et al. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2009 Jan 21; (1): CD005305. 2. Renders CM, Valk GD, Griffin S, Wagner EH, et al. Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings. Cochrane Database of Systematic Reviews 2000, Issue 4. Art. No.:CD001481.DOI: 10.1002/14651858.CD001481. 3. Hartigan et al. Do Team Care Arrangements address the real issues in the management of chronic diseases? Med J Aust 2009; 191: 99-100.

47. Chronic disease management Klersy et al. JACC 2009; 54: 1683-1694

48. Chronic disease management Co-located specialists in primary care Gruen et al. Cochrane Database Syst Rev 2004 Nine met the inclusion criteria (RCT, controlled B/A trials, ITS). Most studies came from urban populations in developed countries Simple 'shifted outpatients' styles of specialist outreach improved access, but no evidence of impact on health outcomes. Specialist outreach as part of more complex multifaceted interventions involving collaboration with primary care, education or other services associated with improved health outcomes, more efficient and guideline-consistent care, and less use of inpatient services. Up to 30% reduction in future events requiring hospitalisation Additional costs of outreach balanced by improved health outcomes

49. Chronic disease management Co-located specialists in primary care –Jackson C, Russell A, Spurling G, et al WCIM 2010 Inala CDM Program for patients with complex type 2 diabetes mellitus Community-based general practice with care delivered by a multidisciplinary team of allied health professionals and up-skilled general practitioners who undertook a structured education programme delivered by an endocrinologist who provided ongoing on-site support Evidence based protocols were adopted and individualised care plans were developed for the patients incorporating principles of self- management Service evaluated and compared with a control group of similar patients whose care was provided at the tertiary hospital Significantly greater percentage of patients achieving all 3 targets –HbA1c ≤7.0% –BP ≤130/80 –LDL cholesterol ≤2.5 mmol/l 24% vs 10%; p<0.001 Sustained funding model needed to maintain new care model

50. Chronic disease management Telehealth –Access to ‘live’ interactive specialist consultation under-staffed regional and rural centres RCFs –More efficient use of clinics –Fewer unnecessary referrals for hospitalisation –Patient and referrer messaging

51. Ambulatory care Access to palliative care expertise in hospital care Early aged care intervention programs Need for more advance care planning –More universal use of advance care directives and palliative care programs in RCFs Reduce hospitalisation rates by up to 40% »Molloy et al. JAMA 2000 »Levy et al. J Palliat Med 2008 »Badger et al. Palliat Med 2009 Shift family/carer expectations towards more conservative care for patients with severe dementia »Mitchell et al Engl J Med 2009 Hospital-based clinics Chronic disease management End-of-life care

52. Principles of Q+S improvement Scott I, Phelps G Intern Med J 2009; 39: 347-351 At multiple levels unit department hospital network

53. What distinguishes successful from non-successful hospitals? Use of data and acceptance of data Different departments working together on common agenda Good physician-management relations –Good connect between middle managers and senior executives –Engagement of clinical departmental heads Engaged quality improvement staff (vs ‘learned helplessness’) Systematic establishment of infrastructure, processes and performance review systems for continuous improvement Strategic alignment and integration of improvement efforts with organisational priorities Active development of clinical champions, teams and staff Absence of an organisational ‘metabolic syndrome’ Note: none of the interventions directly targeted hospital’s ‘culture’ or ‘leadership’ Behal & Finn Acad Med 2009; 84: 1657-1662 Wang et al Jt Comm J Qual Patient Saf 2006; 32: 599-611

54. Generic Q+S indicators Standardised mortality ratios LOS – relative stay index Unplanned readmissions Complication rates Critical incidents Complaints Unplanned transfers OT/ICU/CCU/HDU –Hospital-wide –Diagnosis-specific –Unit-specific Pressure areas DVT/PTE Falls Nosocomial infections Medication errors

55. Unit- or condition-specific Q+S indicators AMI –Process Reperfusion PCI Discharge medications Cardiac rehabilitation –Outcome In-hospital death Readmissions 6 or 12-month mortality ……… for other high volume, high risk conditions associated with evidence-based indicators

56. Quality and safety scorecard DimensionIndicatorTarget Effectiveness/ appropriateness Clinical audits for top 5 DRG Screening procedures for risk conditions Risk-adjusted mortality (-DNR) Readmissions Discharge processes >80% pts receive optimal care >80% at risk patients screened Agreed benchmark >80% discharge plans CapacityStaffing levelsAgreed benchmarks SafetySAC 1 + 2 Medication errors VTE prophylaxis Falls Agreed benchmark AccessClinic waiting time new referral<2 weeks EfficiencyMedian LOSAgreed benchmark Pt centrednessPatient satisfaction survey>80% patients satisfied

57. Is all this data being used in the most effective way to drive QSI? No – why not? –Front-line clinicians rarely see this data If they do they question its validity and usefulness –Accuracy of the data is questioned –Insufficient sample size –Data is not timely or relevant –Absence of agreed benchmarks –Not used to direct investment in SQI Accreditation Credentialing Marketing Funding applications for more resources Politics –No closing of the loop

58. Clinical Governance Scorecard Princess Alexandra Hospital, June 2010 KPITopicTargetScore 1Patient Satisfaction Rate>95%97% 2Complaints resolved within 35 days>80%94% 3Staff Satisfaction (engagement) Rates>42%46% 4Hospital Standardised Mortality Rate<90%78% 5AMI pts discharged with appropriate medications>80%95% 6VLAD timeliness (LL3 reported on time)100% 7Deaths reviewed as per PAH process.100% 8Rapid Response Team utilisation rates per 1000 admissions56 - 2626.8 9Cardiac Arrests per 1000 admissions<1.32.3 10 Appropriate VTE prophylaxis for at risk patients (medical and surgical) >75%79% 11Low risk patients receiving inappropriate VTE prophylaxis.<5%13% Note: Due to using existing data collection methods, not all data is from the same time periods. Results shown is the most recent available for that indicator

59. Clinical Governance Scorecard Princess Alexandra Hospital, June 2010 KPITopicTargetScore 12 ACHS Indicators with a statistically significant worse rate than peer group aggregate rate. <50%20% 13 Units fully compliant with the Clinical Governance Clinical Audit and Review Implementation Standard >90%70% 14 Rejected blood tube rate for samples collected by non- phlebotomist. <0.66 % 1.37% 15INR >5 with subsequent dose adjustment>90%100% 16 Healthcare Associated Staphylococcus Aureus Blood Stream Infections per 1000 bed days < 0.180.13 17Surgical Antibiotic Prophylaxis>90%86% 18 Med History taken within 24 hrs of admission (weekend & midweek) >80%67% 19Pressure Ulcer prevalence rate (post admission)<11%8% 20Triage of SAC 1 events in relation to type of review required>90%100% 21Falls resulting in significant harm per 6 months.< 810

60. Clinical Governance Scorecard Princess Alexandra Hospital, June 2010 KPITopicTargetScore 22 Full or partial implementation of recommendations from RCAs in past 12 months >80%100% 23Open Disclosure offered in SAC 1 events-. 24Med Safety Self Assessment Score-. 25WHO Surgical Safety Checklist Compliance-. 26Patients admitted via ED within 8 hours (YTD performance)>64%57% 27ED patients seen within triage times (YTD performance)>64%56% 28 ED time to AB's in pts with Systemic Inflammatory Response Syndrome (SIRS) >80%66% 29Psych pts with post discharge 7 day follow up100%97% 30Episodes of seclusion08 31Medical Credentialing (% Drs Credentialed)100% 32Medical Specialists with tri-annual SMPR>90% 96% 33 Communication training undertaken by clinical staff since 2006 - 2009 >50% 29%

61. Closing comments Professor of Health Architecture Ian Forbes –Hospitals (and perhaps all health care services) traditionally have operated rather like a medieval joust, with various groups standing under their shields and operating entirely within their own little worlds –What we need is a greater focus on multidisciplinary and multi-team care centred on patient needs (not those of providers), better connectivity between hospital and community teams, and greater use of existing data for facilitating and evaluating quality of care

62. References Brand C, Scott IA, Greenberg PB, Sargious P. Chronic disease management: Time for consultant physicians to take more leadership in system redesign. Intern Med J 2007; 37: 653-659. Scott IA, Poole PJ, Jayathissa S. Improving quality and safety of hospital care: a reappraisal and an agenda for clinically relevant reform. Intern Med J 2008; 38: 44-55. Scott IA. Chronic disease management: a primer for physicians. Intern Med J 2008; 38: 427-437. Brand CA, Cameron PA, Greenberg P, Scott IA. Health services under siege: the case for clinical process redesign. Med J Aust 2008; 189: 239. Brand CA, Ibrahim JE, Cameron PA, Scott IA. Standards for healthcare: A necessary but unknown quantity? Med J Aust 2008: 189: 257-260. Scott IA. Healthcare workforce crisis: too few or too disabled? Med J Aust 2009; 190: 689-692. Scott IA. What are the most effective strategies for improving quality and safety of healthcare? Intern Med J 2009; 39: 389-400. Scott IA, Phelps GE. Measurement for performance: getting one to follow the other. Intern Med J 2009; 39: 347-351. Scott IA, Jayathissa S. Quality of drug prescribing in hospitalised older patients – do we have a problem and can we improve it? Intern Med J 2010; 40: 7-18. Scott IA. Public hospital bed crisis in Australia: too few or too misused? Aust Health Rev 2010; 34: 317-324. Scott IA. Preventing the rebound: improving care transition in hospital discharge processes. Aust Health Rev 2010 (in press).