Politicians! You Heard It From Carmen Lawrence In 1995
"We need to measure outcomes and performance. We need to ensure that the system has a clear and strong patient focus. We need to actively address the problem areas."
Carmen Lawrence, 1995
In 1995, Carmen Lawrence urged parliament to take immediate action.
Australia is still waiting ...
This is the full text of her speech to Federal Parliament.
Dr LAWRENCE (Fremantle-) (Minister for Human Services and Health) —by leave—
"The quality of health care in Australia is a matter of great significance to governments, to health professionals and, most vitally, to all Australians who need health care assistance. This statement reports to the House the first results of an important study—the Australian hospital care study—which presents a challenge to governments and to health professionals. I will describe these results and set out the approach that the government plans to take to respond to the challenge of producing better quality care, the need for which the study has starkly defined.
The Australian hospital care study was commissioned and funded by my department as part of the professional indemnity review. The review was set up in 1991 to look at the adequacy of compensation and funding arrangements for health care misadventures in Australia and will produce its final report shortly. As part of its task, the study looked at adverse events affecting patients in Australian hospitals, both public and private, to which they were admitted in 1992. An adverse event is defined in the study as an unintended injury, which results in a disability, which may include a longer hospital stay, or death, and which is caused by health care management rather than the patient's underlying disease.
The study looked at how many adverse events there were, their causes and factors contributing to their occurrence, the levels of disability resulting from the adverse events, and how preventable they were. It must be emphasised that a good many adverse events are difficult to prevent. When people are very ill and treatment is complex and intensive, when they have multiple conditions and when they no longer have the advantage of the robustness of youth, it can be expected that some proportion of cases will result in injury from the treatment itself.
What we need to focus on are the adverse events which are judged to be preventable. It is worth pointing out that adverse events are highly correlated with increasing age, but are not correlated with gender, birthplace, aboriginality, marital status or whether the patient is public or private.
This study, with its focus on the preventability of adverse outcomes, is a world first. It is a vital milestone for improving public and private hospital outcomes for consumers by better measurement of performance and appropriate improvement in practice. The first results of the study—which has been carried out by a consortium from the universities of Adelaide and Newcastle—have only just become available. I am making these results available, at least in this preliminary way, at the earliest opportunity as I believe that Australian health care consumers, professionals and policy makers have a right to know the information as early as possible. Governments and the professions need to be formulating a response without delay. Complete results of the study will be published in the academic literature in the near future.
Key results thus far
The study examined the medical records of over 14,000 patient admissions to 28 public and private hospitals in New South Wales and South Australia in 1992. Around one sixth, or 16 per cent, of the hospital admissions during the year of the study were assessed as involving an adverse event. For about half of these—that is, 8 per cent of the admissions overall—the adverse events were assessed as being preventable.
I should say that the assessments of whether there was an adverse event, and the degree to which it was preventable, was made by two or three experienced medical assessors reviewing each record after an initial assessment by a nurse. In just over half of the adverse events, the resulting disability lasted less than one month; and in another 30 per cent, the disability was resolved in less than 12 months. However, the other 20 per cent resulted in various degrees of permanent disability or even death. For 0.8 per cent of the total medical records studied, the adverse event resulted in death with 0.5 per cent of the total being judged as preventable.
A qualification to these disturbing figures is that, in a proportion of these cases, the seriousness of the patient's underlying condition means they may have died or become severely disabled during the admission, even if the adverse event had not occurred. Nearly half of all the adverse events were associated with an operation, 15 per cent were related to system problems such as inadequate training or supervision or inadequate communication, and 13 per cent were diagnostic errors. About 75 per cent of the adverse events occurred in an acute hospital, with around 8 per cent occurring in a doctor's office.
While the study sample involved just 28 hospitals in two states, the study methodology is rigorous and should allow the results to be applied to the Australian hospital system as a whole. I will table a paper shortly setting out in more detail the background and methodology adopted by the study.
If the study results were generalised to Australia as a whole, 230,000 public and private hospital admissions in 1992 would have involved an adverse event which was preventable. It is of great concern to me that between 25,000 and 30,000 people would have experienced an adverse event that resulted in some degree of permanent disability, and between 10,000 and 14,000 people would have died. It must be stressed that, although the actual timing of many of these deaths may have been preventable, death itself may have been highly likely because of frailty or the severity of the person's illness.
The human implications of these results are clearly a matter of considerable concern to me, as I am sure they will be for all of you and for other health ministers in Australia. As I have said earlier, I have decided to release them now, so that they can be a trigger for effective action. There will be a closer examination of the study when it is published, but I believe that the evidence is sufficiently stark to warrant immediate action.
In addition to the human implications of these figures, these findings indicate another cost as well. The total hospital bed-days attributable to adverse events in 1992 on the basis of the study figures is 3.2 million, with around half of these relating to preventable adverse events. This preventable proportion amounts to over 8 per cent of all bed-days in that year. A reasonable estimate of the cost of these bed-days would be around $650 million.
I believe it is vital that action is taken by the Commonwealth, the states, who are responsible for public hospital management, private hospital proprietors and the professions to address these issues as a matter of urgency. Today I have written to state health ministers and I will be raising these issues at the Health Ministers Forum to be held tomorrow and the Health Ministers Conference to be held on 15 June. I have also taken steps to consult with relevant professional organisations.
What can we do?
The results of the study are not welcome news. They are, however, a call to action. We can be satisfied that we have had the courage to do the study fully and rigorously—few other countries have done so. Now we must respond to the challenge it represents. More analysis is needed of the data obtained in the study before we know the areas of highest priority for action and before proper prevention strategies can be developed. The consortium is proceeding with this analysis at the moment. However, I believe we need a concerted effort from all interested parties.
When, as part of the study, medical reviewers were asked where efforts should be directed to prevent recurrence for each adverse event that had any possibility of preventability, the area of quality assurance and peer review was cited in 56 per cent of cases. The next highest rated area was communication at 11 per cent. So it is clearly this area of quality assurance and peer review that offers the most scope for measures to reduce preventable adverse events.
One can be encouraged in this regard by the experience of anaesthetics which, despite its inherent dangers, was assessed as being related to only two per cent of the adverse events in the study. This seemingly low result can be attributed to the strenuous efforts of the anaesthetists in Australia over the years to establish and continue a system whereby adverse events are reported and investigated—in particular, anaesthetic deaths are individually closely examined and the assessments reported from time to time in a public document. A not dissimilar process has been adopted for maternal deaths.
It is this culture of measurement of outcomes, assessment of the causes of problems and adoption of measures to address them that we need to encourage throughout the system. I will be proposing to my health minister colleagues and to the leaders of the health professions that a task force be established to examine and report to governments and to the professions on the further work that needs to be done and the measures that should be adopted to improve the hospital system's outcomes.
I will propose that the task force be chaired by Dr Bruce Armstrong, Director of the Australian Institute of Health and Welfare, and that it have a high level membership drawn from the leadership of the health professions, from government, both federal and state, from consumers and from the research consortium which undertook the Australian hospital care study. It should report to the professions and governments within six months.
It is my expectation that this task force will be able to use the results of the Australian hospital care study to develop a set of clear proposals for quick and effective action that hospitals and the health sector can take to reduce the number of preventable adverse events. This study provides a good basis for the health industry to analyse the causes of these adverse events and develop appropriate responses. The study also shows the necessity for the enhanced work on establishment of quality indicators that the government announced in the budget.
The national hospitals outcomes program is a $14.5 million program over three years to develop and implement nationally consistent performance measures for standards of quality and outcomes of care in Australian hospitals. These performance indicators will be used by hospitals and governments for quality assessment and improvement, including benchmarking activities. The program supports demonstration activities that will assist hospitals to respond with quality and outcome improvements and continue to develop incident reporting arrangements.
Conclusion
We can no longer be complacent about the issue of patient safety in health care. It is no longer satisfactory for us to simply assert that we have a high quality health system. We need to measure outcomes and performance. We need to ensure that the system has a clear and strong patient focus. We need to actively address the problem areas. I congratulate those who carried out the study—the challenge of response lies before us. I present the following documents:"
History and methodology of the Hospital Care Study, and Australian Hospital Care—ministerial statement, 1 June 1995.