Quality improvement in healthcare in New Zealand Part 1: what would a high-quality healthcare system look like? By Mary Seddon Summary for Brilliant New Zealand ltd by Malcolm Macpherson This Series attempts to define what a high-quality healthcare system would look like for New Zealand, focusing on the dimensions of a quality service: safety, access, equity, effectiveness, efficiency, and patient centeredness; not only elucidating in plain language what these dimensions are, but how they might be measured and improved. The central premise is that clinicians need to become involved in measuring and improving the quality of healthcare provided. The Series covers ways to measure the effectiveness of care, with articles on clinical audit and clinical indicators, and the pros and cons of the measures of efficiency used by funders: performance indicators and benchmarking. The Series will wrap up with a vision of how we might continue to improve quality through embedding clinical governance into District Health Boards, so that their performance is measured in both quality and fiscal terms. On the 16 February 2006, the Quality Use of Medicines (QUM) group presented their strategic national plan to incoming Minister of Health Pete Hodgson. He listened and asked pertinent questions, and used his experience as a veterinarian to empathise with how easy it was to make a slip error with medications. However, during discussion he said something like I don't know what quality is all about, no-one can define it clearly, and [seeing my raised hand] no I don't want any more definitions. While this might worry those of us who have been working in healthcare quality, it is probably an accurate reflection of not only the Minister's frustration, but also the frustration of many others within the healthcare sector. Why is it so difficult to define what a high-quality healthcare system would look like? Partly this difficulty derives from different perspectives and responsibilities. The Minister is responsible for the entirety of the health sector from the individual care provided in the primary sector, through the complex decisions around funding expensive drugs in secondary care, right onto planning for a possible bird-flu pandemic. He also has responsibility to see that care is provided in a fair, equitable way without reference to whether someone lives in Southland or Auckland, or on their ability to pay for care. Furthermore, he must address those large health promotion issues such as smoking and the obesity epidemic. Advocates for each of these areas have been making time to speak with the Minister to put their particular point of view and push for increased resources for their subset of the health sector. The Minister must balance these demands with his need to take a population view and make the best use of the available resources. His working definition of healthcare quality will necessarily be different from that of the front-line clinicians whose responsibility for quality revolves around the individual/clinician interface. The concern here is primarily around technical excellence: doing the right thing (appropriate care based on the best available evidence) and doing it right (delivering safe, timely care). Patients will have a different definition depending on whether they are awaiting elective surgery (where access and timeliness might be the main indicator of quality), or whether they have a chronic disease (where coordination of care might be the most important). However, these different quality worldviews should not deter us from defining what a high-quality healthcare service would look like. We could ask learned committees to come up with definitions. One of the most often quoted comes from the American Institute of Medicine which defines healthcare quality as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. While this definition touches all the right buttons, highlighting healthcare quality for both individuals and populations, focusing on desired outcomes (presumably desired by patients) and evidence based medicine, it is a little difficult to operationalise. As discussed, the definition of quality depends on where in the health sector each player sits and one approach to defining healthcare quality is to customise the definition from these different viewpoints. Another way forward is to break down quality into the dimensions that would define a high-quality healthcare system. Using this approach and incorporating the different player's perspectives a framework for Quality Improvement was developed by the National Health Committee and has since been included into the Ministry of Health's Improving Quality strategy. For the clinician and the clinical team perhaps the two most important dimensions are safety (first do no harm) and effectiveness. Safety (or the lack of it) in healthcare has become a cause celebre since the Institute of Medicines' 2000 publication, To err is human: building a safer health system. The analysis of the previous decade's work on the incidence of harm from medical management (adverse events) estimated that between 44,000 and 98,000 Americans died as a result of the care they received. Even if the lower estimate is closer to the truth, this would make deaths from adverse events the seventh leading cause of death, higher than the deaths due to motor-vehicle crashes, AIDS, or breast cancer. And no, this is not a problem peculiar to the United States of America, similar studies in the United Kingdom, Australia, and New Zealand confirm the universality of the issue. The New Zealand study estimated that 12.9% of hospital admissions were associated with an adverse event, around 14,000 patients per year, and that a third of them were preventable. A fuller investigation of the safety dimension, the causes of unsafe care, and efforts to improve it, will be the subject of the next article in this Special Series. Effectiveness can be defined as making appropriate decisions based on the best available evidence, avoiding overuse (providing care of no proven benefit or in situations where the benefits are outweighed by the risks) and underuse (failing to provide care of proven benefit). The third article in this Series will explore the effectiveness dimension of quality in greater depth and outline the role of clinicians in measuring the effectiveness of the care that they provide. It will specifically cover clinical audit and then the fourth article will look at how to best use clinical indicators. The central premise of these articles is that the involvement of clinicians in the measurement and management of quality is essential to improve the quality of care delivered. Many doctors have been sceptical of the various quality improvement mantras, but critically analysing how effectively we deliver care is actually embedded in our professional ethos, and while there may be reasons why some have lost sight of this (little patient-free time, ever-expanding work commitments, little teaching in quality improvement measures, cumbersome administrative demands), it is now essential that clinicians take a lead in quality improvement, otherwise they risk imposition of measures by those removed from the realities of the shop-floor. The fifth article in the Series will focus on those global measures that District Health Boards (DHBs) and the Ministry of Health demand to assess the efficiency of the healthcare system. Efficiency is predicated on a service delivering an effective service so that it can make the best use of available resources. This article will therefore outline the pros and cons of outcome indicators and the use of benchmarking. There is of course no point in having a safe, effective, and efficient healthcare system if patients are unable to access it. Timely and equitable access to care has been a political focus since the 1980s. In 1992, the National Advisory Committee on Core Health and Disability Support Services (the Core Services Committee) tried to develop a nationally explicit set of core services to which all New Zealanders would have access. It eventually rejected the concept of a core service, arguing that few treatments were ineffective in all patients, and exclusion of whole services would be unfair to the patients who may benefit. It suggested an individual benefit approach to determine resource allocation and from this has come the Clinical Priority Assessment Criteria for a number of surgical operations. The success (or otherwise) of this innovative approach to healthcare quality is still to be evaluated, we do not yet even have reliable systems to measure the number of operations that we do in the public sector, and equity of access is still a political hot-potato. The sixth article in the Series will explore the ‘patient-centred’ dimension of quality. Although not explicit in the Ministry of Health framework the importance is seen with the centrality of the patient in the diagram. In addition, Treaty of Waitangi principles have been added, including the concepts of partnership, participation, and protection. This is apt given the growing interest in patients (and their families) taking control of their care, being active partners in decision-making, and ensuring provision of acceptable care. It is perhaps embodied by Don Berwick's (Institute for Healthcare Improvement) statement, nothing about me without me. The final article in the Series will explore how clinical governance might be used to improve healthcare quality and to ensure that any gains are held. Clinical governance in essence charges healthcare executives with not only being fiscally responsible but also responsible for the quality of the clinical care provided, a point noted in the Bristol Inquiry. We hope that this series of articles will guide the Hon Pete Hodgson (and NZMJ readers) as to what a high-quality healthcare system would look like, and provide some tools for clinicians to achieve such a system.