Health care, safety, performance and quality in New Zealand A partial review of current thinking This page is a table of contents for health-sector related papers and articles about quality. There are brief statements of content, links to on-line summaries for Brilliant New Zealand Ltd by Malcolm Macpherson, and some relevant commentary Commentary What is quality in a healthcare context? Here at Brilliant New Zealand Ltd, with our emphasis on performance excellence and our skepticism about the Q word (and our long grounding in Baldrige and international derivatives), we are increasingly convinced that a clear answer to that question is key to progress. While we in New Zealand collectively fail to understand and clearly state what the enablers of high performance look like, and the health and disability sector (and community and polity) continues to obsess about audit, assurance, aggregate indicators and signal events, an opportunity to move from occasionally OK to internationally brilliant is being lost. The last paper in the much-heralded NZMJ Series (link below) captures this dilemma. Clinical Governance is proposed as a solution to system and sector improvement; as a way to cut through the dysfunction and poor performance of New Zealand's recent past. But then the paper fizzles out in a limp agreement that there's not much evidence that it works, and the eager, convinced reader is left with no sense of mission. Why? Because the paper fails to recognize (in spite of words to that effect in early paragraphs) that there has to be a process. More, there has to be effective diagnosis, and a structure for identifying strengths (the things we want more of) and opportunities for improvement. That's what brilliant New Zealand offers. Not rocket science. Grounded in the combined 30 years of international experience of the two principals. Known to be effective. In their prescription for a course in quality in health care (POPLHLTH 724: Quality in Health Care), the University of Auckland subtitles the course with the comment that "Improving quality in health care is a primary focus for health systems which are seeking to manage demand, error, cost and the drive to fund new technologies and techniques." Confusion is rife An example: the 2004 paper by Buetow and Coster, summarised here. And here's Malcolm Macpherson's comment. The New Zealand Medical Journal series In 2006 members of the Effective Practice Informatics & Quality (EPIQ) group based at the School of Population Health, Faculty of Medicine and Health Sciences, Auckland University, wrote a series of 7 articles about Quality in Health Care, published sequentially in the NZMJ. Malcolm Macpherson has summarised these papers for Brilliant New Zealand Ltd. The titles are listed below, with links to each summarised paper. Seddon M. Quality improvement in healthcare in New Zealand. Part 1: what would a high-quality healthcare system look like? N Z Med J. 2006;119(1237):U2056 Merry A, Seddon M. Quality improvement in healthcare in New Zealand. Part 2: are our patients safe - and what are we doing about it? N Z Med J. 2006;119(1238):U2086 Seddon M, Buchanan J. Quality improvement in New Zealand healthcare. Part 3: achieving effective care through clinical audit. N Z Med J. 2006;119(1239):U2108 Buchanan J, Pelkowitz A, Seddon M. Quality improvement in New Zealand healthcare. Part 4: achieving effective care through clinical indicators. N Z Med J. 2006;119(1240):U2131 Perkins R, Seddon M. Quality improvement in New Zealand healthcare. Part 5: measurement for monitoring and controlling performance - the quest for external accountability. N Z Med J. 2006;119(1241):U2149 Robb G, Seddon M. Quality improvement in New Zealand healthcare. Part 6: keeping the patient front and centre to improve healthcare quality. N Z Med J. 2006;119(1242):U2174 Perkins R, Pelkowitz A, Seddon M. Quality improvement in New Zealand healthcare. Part 7: clinical governance - an attempt to bring quality into reality. N Z Med J. 2006;119(1243):U2259 Different writers, similar conclusions The Auckland group haven't been the only commentators. Barnett and others (2004) pursued similar themes in the Journal of the NZ Medical Association. Professional leadership and organisational change: progress towards developing a quality culture in New Zealand's health system By Pauline Barnett, Laurence Malcolm, Lyn Wright, Christine Hendry Journal of the New Zealand Medical Association, 23-July-2004, Vol 117 No 1198 Summary by Malcolm Macpherson for Brilliant New Zealand Ltd, Friday, February 22, 2008 Does publishing performance data improve quality of care? In a 2008 Annals of Internal Medicine paper reviewing the evidence that publishing patient care performance data improves quality of care, Fung et al note that while reports on the quality of care show improvement in many clinical areas, quality deficits remain. The US health care system often fails to deliver effective, safe, and patient-centered care (3 areas that the Institute of Medicine has identified as important for a well-functioning health care system). Lack of a transparent, explicit, systematic, data-driven performance measurement and feedback mechanism for health care providers has contributed to these failures. The public release of performance data has been proposed as a mechanism for improving quality of care by providing transparency, and increasing the accountability of providers. Public reporting can improve performance through 2 pathways: 1. in a selection pathway, patients or their intermediaries compare publicly released performance data and reward the better-performing providers by selecting (rewarding, recognizing, punishing, or paying) the provider 2. In a quality improvement pathway, performance data help providers identify where they underperform, and they improve their performance. In this paper, high performance seems to be seen as a necessary precursor to quality, which these authors propose, without elaboration, to be a focus on improve clinical outcomes (effectiveness, patient safety, and patient centeredness). These authors found rather poor correlations between performance improvement activities and public reporting of performance metrics, suggesting that making public performance data is not a strong incentiviser of improvement activity. They were unsure why! Constance H. Fung, MD, MSHS; Yee-Wei Lim, MD, PhD; Soeren Mattke, MD, DSc; Cheryl Damberg, PhD; and Paul G. Shekelle, MD, PhD. Systematic Review: The Evidence That Publishing Patient Care Performance Data Improves Quality of Care. Annals of Internal Medicine 2008; 148:111-123 What works in the USA? The Institute of Medicine, part of the US National Academy of Sciences, recommended last week that the country needs an independent program to evaluate "which diagnostic, treatment, and prevention services work best for various patients and circumstances." BALDRIGE! North Mississippi Medical Centre - Baldrige application summary Bronson Methodist Hospital - Baldrige application summary Mercy Health System - Baldrige 2007 winner We never talk any more Comment from the pages of the British Medical Journal, offered completely unedited, which makes the point, just in case you'd missed it, that all is not well in the British health system! By James Owen Drife, professor of obstetrics and gynaecology, Leeds