New Zealand health quality & safety commission – Making progress

---

Since forming four years ago, the New Zealand Health Quality & Safety Commission has made great progress and is now entering, which its chief executive Dr Janice Wilson calls ‘the second phase’ of its life.

---

The Kiwi equivalent of the Australian Commission on Safety and Quality in Health Care was established in November 2010 with a triple aim:

•  improved quality, safety and experience of care


•  improved health and equity for all populations


•  best value for public health system resources.

“We have helped create a momentum of ‘quality improvement’ in health over the past four years, especially in the hospital sector,” Dr Wilson said in a New Year bulletin to Commission staff.
“We can measure, quantify and describe our successes. “Our challenge now is to similarly galvanise the community sector (without taking our eye off the hospital sector) with creativity and enthusiasm into new ways of thinking about and undertaking quality improvement.”
The Commission has already made forays into the community sector, including its Let’s PLAN for better care health literacy resource - an A4 sheet to help patients get the most out of their general practice visits, while also encouraging them to ask pharmacists about their medicines.
As part of its ongoing Open for better care national patient safety campaign, the Commission will, from April for six months, focus on preventing harm from falls in aged residential care and home care.
Other steps ahead include extending regular patient experience surveys of hospital inpatients to include surveys of primary care patients, possibly followed by pilot programs with some of the country’s primary health organisations (PHOs).
“Traditional patient safety programs have been hospital-based,” says Dr Wilson; “because one, it’s a more confined environment so it’s easier to implement, easier to find a problem and think about how to measure it and what to do, and two, significant harm in terms of the effect on consumers and on the economy happens in hospitals. “So, they’re a sensible place to start.
“Primary care and the community are more diffuse and it’s harder to define what some of the key problems are. “They’re often not as significant in their impact in terms of the patient’s experience and costs to the system. “Yet it’s where most people go. “The vast majority of the public will see their primary care practitioner much, much more than they ever will a specialist.
“So, we do need to think about what’s best quality and how do primary care services think about their quality improvement activities? How do they measure how they’re doing? Do they look at their Atlas of Healthcare Variation results? Do they look at how they compare with each other? How do they change their practice based on as the results found from, for example, global trigger tools?”
With New Zealand’s older population burgeoning (as in other countries), aged residential care and supported services are also an area for attention, along with the disability and mental health sectors.
The first phase
It has taken four short but intense years for the Commission to grow in numbers – to a staff of nearly 50 – and capability to reach its ‘second phase’.
The first phase dates from December 2009, when, after a review set up by then Health Minister Tony Ryall, the New Zealand Cabinet agreed to strengthen the health sector’s focus on quality and safety by replacing the Quality Improvement Committee based in the Ministry of Health with a standalone Crown agent independent of the Ministry’s regulatory, funding and performance monitoring functions. It was thought this would better position the new Commission to maintain the confidence and engagement of health professionals.
Professor Alan Merry, head of the School of Medicine at the University of Auckland and a practising anaesthetist and chronic pain specialist, has been chair of the Commission since the start.
He remembers it being ‘all hands on deck’ in those early days, as they scoped the form the Commission might take, talking to people from across the New Zealand health sector, and looking at other patient safety organisations, including in Australia.
“It’s a world where everyone shares resources and is remarkably supportive” says Prof Merry, while Dr Wilson adds that the New Zealand and Australian Commissions “think of ourselves as sister organisations”’ and “the Australians said from the outset that whatever we have you can have”.
One organisation the Commission spoke to early on was the UK’s National Patient Safety Agency. “They were being disbanded at the time we were being set up so we had quite extensive discussions with the people involved with that to ask them why they had reached this point,” says Prof Merry.

---

“Many of the New Zealand Commission’s activities will be recognisable to those familiar with its Australian counterpart, albeit sometimes in different forms, on a different scale or at a different stage of development.”

---

Embracing partnership
From the outset, the Commission was keen to work with the health sector as partners.
“We took the view early on that by and large we have a good health care system and that what we want to do is assist those that work in it and capitalise on their motivation to do well,” says Prof Merry. “There are good staff – nurses, doctors, managers – that are committed already and doing well. Our job is just to try and help them do even better.
“We didn’t want to rush in and say a whole lot of arbitrary things and add to their burden. “We wanted to minimise the burden of compliance but maximise the tangible benefits of improvement initiatives driven by clinicians from the workface. “People would see why we wanted to do things and it would make sense to them to do them.
“And we continue to work on that basis. “Everything I see suggests almost everybody in the health system in New Zealand is motivated to do good work and avoid harm to patients, and in fact we have got good systems on the whole. “But there are gaps and areas where it’s possible to help people to just continue to get better.’”
Partnering with patients, families and carers is a priority, too. The Partners in Care program is built on growing evidence of the importance of such partnerships, with potential benefits such as improved outcomes, enhanced experience of care and increased workforce satisfaction.
Partners in Care milestones for the Commission include the development of a strong, diverse consumer network and co-design collaborations between health professionals and consumers.
Sisters but not identical twins
Many of the New Zealand Commission’s activities will be recognisable to those familiar with its Australian counterpart, albeit sometimes in different forms, on a different scale or at a different stage of development.
The New Zealand’s Commission’s Atlas of Healthcare Variation maps of New Zealand, for instance, were introduced in 2012 and are well-established. There are atlases covering 12 clinical domains, from asthma to trauma services, with community dispensing of opioids the latest, complementing an 18-month national collaborative for the safe use of opioids within hospitals. The atlases include such demographic information as gender, ethnicity and age, as well as geographical location.
The Australian Atlas of Healthcare Variation is still in development and is due to launch this year.
Conversely, the Australian Commission is further ahead in its work on the clinical deterioration of patients, having begun a program in 2008, while the New Zealand Commission is laying the groundwork for a program.
The most significant differences between the Commissions are structural.
Australia has a land mass of more than 7.5 million square kilometres and an estimated population of over 23.5 million people; New Zealand has a land mass of some 268,000 square kilometres and an estimated population of around 4.5 million people.
The Australian Commission has to work with a health system spread across six states and two territories, while New Zealand’s public health service falls under a single national Ministry of Health.
One should not, however, underestimate the diversity within New Zealand and its health system.
There may not be states and territories, but there are 20 district health boards (DHBs) operating public health services in different regions of the country, each with its own distinct identity and requirements.
Nonetheless, “the thing we can do in New Zealand, because we are a small country and can engage fast, is get people on board really quickly,” says Dr Wilson.
Under the 2011 National Health Reform Act, the Australian Commission is now responsible for coordination of accreditation using National Safety and Quality Health Service Standards.
The New Zealand Commission does not have this quality assurance role, its focus remaining firmly on improvement. It does, however, have under its umbrella a group of independent mortality review committees, which came to it from the Ministry of Health.
There are four permanent committees dedicated to reviewing, and learning from, the deaths of children and young people, babies and mothers where death is linked to pregnancy or childbirth, deaths resulting from family violence and deaths associated with surgery, plus a temporary committee testing the ground for suicide mortality review.
“The committees have been a strength of the Commission,” says Prof Merry. “The work they do is very important and I’m hoping we can increase and grow that activity over time because it is a major contribution.”
The campaign trail
The Commission’s patient safety campaign, Open for better care, was launched in 2013 to further promote quality improvement, by encouraging the sector to put in place simple interventions that make a real difference.
Every six months, it focuses on a new topic drawn from the falls, infection prevention and control, perioperative harm and medication safety programs, with the Commission working closely with DHBs and offering them a range of evidence-based resources they can draw upon.
Effectiveness is measured through quarterly quality and safety markers, and an independent evaluation is under way.
Taking the measure of things
“Measurement and evaluation are essential for setting the quality and safety agenda, providing a catalyst for improvement and monitoring progress,” Prof Merry said in his foreword to the Commission’s 2014-18 Statement of Intent. “Used wisely, monitoring and reporting on quality and safety can generate engagement by clinicians and consumers, and inform conversations about where problems and key opportunities for improvement exist.”
Other measurement tools the Commission uses include an annual report of serious adverse events (SAEs) reviewed and reported by DHBs under the country’s national reportable events policy.
A growing range of non-DHB providers are voluntarily reporting SAEs, including private hospitals and aged residential care facilities.
The latest quality and safety markers report gives a sense of the ‘momentum’ Dr Wilson is talking about as the Commission moves into its ‘second phase’:

• Thirteen of the country’s DHBs are now using appropriate skin antisepsis preparation aimed at reducing surgical site infections (SSIs) in 100 per cent of hip and knee orthopaedic operations, with the national average of patients receiving appropriate skin antisepsis at 97 per cent


• Intensive care unit central line insertions fully compliant with the bundle recommended to combat central line associated bacteraemia (CLAB) are at 95 per cent, and CLAB infections continue to be less than 1 per 1000 line days


• The percentage of operations where all three parts of the recommended surgical safety checklist are used is 94 percent


• Older patients assessed for their risk of falling are at 89 per cent, with 88 per cent of those assessed as being at risk then receiving an individualised care plan


•  National compliance with the recommended ‘five moments’ of hand hygiene is at 75 per cent, with 15 DHBs at that rate or higher.

“I think our relationship with the health sector as a whole has been very good and that has let us achieve some obvious gains,” says Prof Merry.
“CLAB is one and I think what’s coming through now on surgical site infections generally is really good. I think the hand-washing campaign has been a reasonable success – we are not quite where we want to be but I think we have made a big difference there and need to push that further.
“I think the work we’re doing in surgical harm is really quite innovative. What’s happened recently, with people starting to move away from tick-box approaches and engaging with what really matters with the surgical checklist, and with briefings, is great, an indication of us working with people to make change that is meaningful.
“We really try not to be a compliance organisation but an organisation that facilitates people at the workface to engage with problems and come up with solutions that really work.’
For more about the New Zealand Health Quality and Safety Commission, visit www.hqsc.govt.nz.