Victoria’s health system must get better at sharing success stories to avoid preventable harm to patients, says Kym Peake, the secretary of the Department of Health and Human Services.
A review of Victoria’s hospital system, following the discovery of a cluster of potentially avoidable newborn and stillborn deaths at Djerriwarrh Health Services, has found serious shortcomings in the department’s support for the state’s hospitals, including inadequate governance and oversight arrangements.
In response to the report, the government will establish a new agency called Safer Care Victoria, which will be dedicated to monitoring and improving quality and safety to work towards zero avoidable harm in our health system.
“While many Victorian health services have achieved laudable safety and quality improvements in various areas of clinical practice, the department has not made these improvements commonplace,” said Grattan Institute health program director Stephen Duckett, who led the review. “As a result the Victorian hospital system is full of isolated success stories that are not shared across hospitals, and that the majority of patients do not benefit from.”
“In Victoria many health services are working tirelessly … But to a large extent they are doing so with inadequate support from the department, whose approach to safety and quality does not carry the level of attention, investment and priority that the issue requires. The department has inadequate overarching governance and oversight of safety and quality, and is doing too little to lift the capacity of the Victorian health system to improve quality and safety,” Duckett stated.
People expect that where mistakes are made, lessons will be learned, said Health Minister Jill Hennessy. The review found “the Department of Health and Human Services has failed to provide adequate oversight of quality and safety across our health services,” she noted.
“There are gaps and failings in our quality and safety systems that have been overlooked, and the action and leadership required from the department to achieve change and prioritise patient safety has not occurred.”
Departmental secretary Peake acknowledged the need for change. The department “must take a stronger role as system leader and system manager”, she said. DHHS is addressing the review’s recommendations under four areas of emphasis, according to the secretary:
- setting the goal that no one is harmed in our hospitals;
- supporting strong leadership in hospital governance;
- sharing excellence across our health system;
- collecting data about patients’ experiences and feeding that across the system.
“This will mean change for the department, which we welcome. We’ve already increased the priority we place on safety, quality assurance and improvement in Victorian health services,” Peake stated.
“We’re committed to providing greater oversight and stronger leadership, working with our hospital boards, our clinicians, and with our healthcare workforce.
“We must share our learnings, we must share our insight if things go wrong, and share the knowledge from our successes.
“Victorians deserve to know that should things go wrong, their needs will be dealt with swiftly and transparently, and any lessons learned and shared across the hospital system. Patients, families and carers need to be empowered to be partners in their own health and healthcare.”
Health system overhaul
The Victorian government has announced a suite of changes to restructure the state’s health system in response to the review.
It will establish Safer Care Victoria, a new agency dedicated to monitoring and improving quality and safety to work towards zero avoidable harm in our health system. The body will be led by clinician and researcher Professor Euan Wallace, and will be focused on patient safety, identifying best practice ideas and initiatives, and expanding them across the health system.
The government has accepted in principle all recommendations made by the review, and work is already underway to implement them. Actions include:
- A new health information agency to overhaul the way data and information are shared across the health system so the state knows where the concerns are, and where things are going well;
- The creation of the Victorian Clinical Council to provide clinical expertise to the government, the department and health services on how to make our hospitals safer for Victorian patients;
- Public and private hospitals being held to the same quality and safety standards and reporting requirements;
- Consultation on a duty of candour law where health services must apologise to any person harmed while receiving care, and explain what went wrong and what action will be taken;
- Examining the option of extending no fault medical insurance for health care injuries — similar to compensation schemes for injuries in the workplace and from motor vehicles;
- A new ministerial board advisory committee to make sure hospital and health service boards have the right mix of skills, knowledge and experience to strengthen local governance and decision making;
- Providing boards with the information they need to hold their chief executives to account and the training they need to improve performance;
- Ensuring that wherever possible regional Victorians will receive care closer to home, but making sure those with complex conditions have the support they need to travel to receive safe, quality care in an appropriate hospital setting — usually in a regional hub;
- The development of master plan options for the Thomas Embling Hospital, along with staging and delivery considerations, in line with the current and future needs of the service;
- And increasing the mental health workforce by funding an additional 130 mental health staff to better meet demand.
A new safety and quality bill will also be introduced into parliament next year to address a number of the recommendations, with a major review of the Health Service and Ambulance Service Acts to follow.