The Challenge of Quality and Safety in the

Emergency Department in 2014

Kylie Stark

Nurse Manager,

Sydney Children’s Hospital Emergency Department and Co-Chair, Clinical Advisory

Group, ECI, NSW

Defining Quality and Safety

The language comes from other High Reliability Organisations that want to

measure sustain and enhance performance.

Safety = free from harm

Quality = Excellence

Establishing and maintaining a culture of Quality and Safety is a constant

challenge in the face of dynamic Health Care Policy and the changing Face of

Population Health

History – far have we come ?

1995:

Quality in Australian Healthcare Study – Wilson, Runciman et al

Identifies 16.6% hospital admits experiencing adverse event with 51%

preventable.

Over past 20yrs there have been numerous reports/investigations/inquiries

driven by crisis in Quality and Safety in Australian Hospitals ( Macarthur/Nth

Shore/Bunderberg/Garling)

History

1997:

Commonwealth Government commits $40 million in Acute Care Health

Reform

• Consumer participation

• Accreditation processes

• Clinical practice guidelines

• Performance measure and benchmarks

• Innovation encouragement

• Health information technology initiatives

History

1998 Health Minister Dr Wooldridge comments re the released report from

The National Expert Advisory Group on Quality and Safe Healthcare,

• “ This important report stresses the need for governments to provide

leadership in improving safety and quality practices and must also ne

addressed by hospital administrators, doctors and nurses in the frontline of

health care “

• ARCHI funded

2000 Australian Council for Safety and Quality Health Care established

(ACSQ)

History

“Safety First “ released – first report of ACSQHC – Health Ministers commit to $50 million to support the agency in National Healthcare Quality and Safety reform

First national action plan released by ACSQHC

• Use data for safer care

• Strengthen mechanisms to support safer clinical and organisational environments

• Consumer feedback and participation

• Design systems and processes of care to support a culture of safety and reliability

History

2001 Safety in Practice released. 2nd report of ACSQHC

• National Institute Clinical Studies established

2002: Second National Action Plan released by ACSQHC

• Open disclosure

• Medication safety

• Healthcare associated infection

• Co-ordinated national action re serious adverse events

History

“Patient Safety” released.

Towards Sustainable Improvement – ACSQHC

Strategies also released to address:

• Open Disclosure

• Healthcare Associated Infections

• Safe Staffing

• Accreditation Systems

• Standards Settings

2012 Release of National Standards

2014 - Are we Safe? Are we Good?

2011-2012 Australian Institute Of Health and Welfare reports 6.1% of public

hospital admissions associated with adverse event.

Should we be perfect ?

So many resources, reports and measures?

Why still so challenging?

Ownership of Role/Portfolio

2014: Where are we now ?

We are more aware

We are more innovative

We are committed in a

way we never have been

We are starting to

measure the right things

We have new challenges

External Drivers

• National Health Budget

• State Health - priorities

• ACSQHC

• ABF

• Infrastructure

• Increasing chronicity

• Ageing population

• Increasing ED activity

• Complex treatments

Internal Drivers

• Workforce:

o Scope of Practice

o Workforce behaviours

o Training needs of tomorrows’ workforce

o Multiple disciplines

o Multiple skill sets

o Skill set variance

o Managing it – recruitment - retention

Internal Drivers

• Clinical Practice:

o New practice

o Old practice

o Variance

o Guidelines – helpful or not

o Standards

o Safety and Quality Tools – BTF/Pathways/Handover

Governance Structures

Leadership

• Direction

• Vision

• Support

• Clarity

• Purpose

• Feedback

Data – our currency

• a HINDRENCE or a

HELP

• What to measure?

• When to measure?

• In creating an

environment that is

free from harm and

excellent in it’s delivery

what data helps ?

Bench-marking

KPI’s

Adverse events

Preventable deaths

DNWs

Valuable data … NSW Incident Management Sx

• We know what was reported

• We know how serious with

SAC scores

• We know where

• We know the themes and the

trends

• Most common themes

Communication

Right patient

Highest incident categories

• Falls

• Medication

• Clinical Management

• Documentation

We can learn lessons and take

action.

Falls programme,

,BTF,PECC,Electronic Medication

Mx,Time out

Performance – what matters ?

• Last year triage performance mattered

• This year it’s about 240 golden minutes!

• Time based measures can reflect

efficiency but do they reflect safety and

quality?

• What happened in that minute??

• What happened in that time??

Competence

• Did skilled people assess with expert eyes?

• Did the right diagnostics get ordered, completed

and interpreted by skilled people?

• Did the right treatment get ordered?

• Did treatment commence?

• Did monitoring continue?

Our patients

• Was the patient informed along the way?

• Was the patient included in the decision

making?

• Was the patient the focus of their journey?

• Were compassion and empathy visible and

constant?

• They are the public face of safe quality

healthcare

Why still such a Challenge ?

Why so different in the emergency department ?

• Its unpredictable

• Its unplanned

• Its dynamic

• Its after hours

• Its workforce is not consistent 24/7 – skill or numbers

• Its cradle to the grave

• Its crowded

• Cognitive load

• Interruptions and distractions

Unique factors

A unique feature in the ED is the high density of clinical decision making.

Limited time and limited information.

Factors like fatigue and sleep debt and cognitive overload can and do

threaten the quality of decision making.

Safety in the ED is linked to thinking and skills.

( issues identified by International Federation for Emergency Medicine 2012)

More Challenges

• Its unspecialised in a world of increasingly

specialised medicine

• Its loaded with time-based KPI’s

• Its consumers have high expectations and high

anxiety

• Risk is a constant

• Change is a constant

What does it look like ?

It looks different to:

• The patient

• The relative

• The doctor

• The nurse

• The administrator

• The executive

ITIs IT Communicatio

n

Skilled

Workforce

Safety

Tools

Equipment and

Space

Audits and Data

Best Practice – minimal

variance Visible

Leadership

A Jigsaw Puzzle

Culture is over arching solution

• Leaders that lead

• Clarity regarding product

• Clarity regarding role

• Education at every level for everybody

• Minimal variance

• Adequate resources

• Make peoples work visible

• Measure and display what reflects safety and quality in

your department

It’s a recipe

Grandma’s cake

• Same ingredients

• Same amount

• Same temperature

• Same vessel

• Same cook

• Same CARE

People – our greatest resource

• Make them accountable

• Respect them

• Delegate to them

• Trust them

• Value, incite, experience and compassion

• Communicate

•Tell everyone everything every time!!

Solutions

• Ownership – find a way to create a Quality Role ( ECI Quality in ED

Project 2012-2013)

Solutions

• Make it part of everything everyday.

• A “just culture” - balance no blame with appropriate accountability

• Not everything is good for everybody – local modification of models of

care/safety tools/processes (CERS)

• Collect data that means something – then make it available to the people it

matters to

• Network and share and support.

• Influence –Whole of Hospital Strategies

• Celebrate the consumer commentary

Solutions

• Measure “ CARE “ – do we have a measure?

• Listen and engage our product – Patients and Families

o “Your most unhappy customers are your greatest source of learning” Bill

Gates

• Influence and control what you can

• Use data – we now know what errors happen, when and why.

• Value knowledge and experience

• Consider the value of Soft Systems – The Relationships (Hugh MacLeod and

Dr. Mary Ditton)

The one free thing !

Our future – We can never be sure ……..