18 September 2017
Why reporting matters for public safety Challenging ideas seminar, 25 August 2017
Dr Stephen Duckett, Health Program Director at the Grattan Institute and leader of the recent state-wide review into hospital safety and quality assurance in Victoria, gave 150 guests from the New South Wales health system a nuanced and thoughtful set of challenges on which to reflect.
Too little progress, too much variation
He kicked off with a quick canter round a number of past national quality and safety initiatives, swiftly contrasted with a confronting graph showing how little change there has in fact been in complication rates. This was quite challenging.
Things got a little more challenging as he highlighted the extent of variation in complication rates between hospitals, even after risk adjustment for patient age, sex, DRG severity and comorbidities. In other words, you are significantly more likely to experience a complication at some hospitals even after accounting for how old or sick you are.
Why aren’t we doing better?
The real challenges started coming when he explored some of the reasons why we aren’t doing better. By way of a discussion about the need to focus on the bigger picture of reducing harm and looking at improving system outcomes overall, rather than getting mired in questions of preventability, Dr Duckett brought us to the central question of transparency and public reporting.
It’s inarguable that clinicians, hospital management and their boards need to know the strengths and weaknesses of their services, and how they compare to others. Dr Duckett contended that they often don’t know and don’t have access to those data. He illustrated this with the endearing, but statistically impossible, finding that almost every member of a health service board in one state thought the overall quality of healthcare in their organisation was as good as or better than the rest. However, he also pointed out that such internal transparency is necessary but not sufficient.
In the UK, he noted, the ‘Getting it Right First Time’ initiative is uncovering huge and persistent differences in performance, such as a 25-fold variation in orthopaedic surgical site infections. The public reporting of these findings is leading to the very challenging idea of limiting the high degree of autonomy surgeons enjoy.
…but public reporting works
Public reporting is crucial, he argued – not because patients and communities are necessarily crying out for this information (yet) but because the fact of it being public harnesses competitive instincts and requires boards, managers and clinicians to pay attention and take action. To that end, he called for the release of risk-adjusted complication rates for individual hospitals at a procedural level.
As well as pointing to the established evidence that public reporting works, Dr Duckett rehearsed some of the familiar counter-arguments, such as gaming and the risk of adverse selection (where hospitals choose not to treat high-risk patients) – though he also pointed to evidence that treating high-risk cases has no adverse effect on hospital risk-adjusted mortality rates.
He emphasised the need to get the style and manner of public reporting right to limit the risk of ‘media frenzy’ and preserve the focus on improvement rather than blame-hinting. This is not straightforward to achieve but Dr Duckett challenged us not to shy away from potentially heated but healthy debates, or we’ll end up with more of the same.
One of the questions that came up in the audience Q&A was from a board member highlighting boards’ appetites for better access to comparative and trend data to support their governance role. BHI has recognised this need, and over the next few months we will be working with NSW local health district (LHD) Boards and executives to develop and deliver tailored quarterly reports directly to them to help drive system improvements. This new report series will support boards to make better use of data by providing high-level comparative and trend information and highlighting key performance issues.
To access the materials from the event, including videos, please see the event page .
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Dr Diane Watson is the Chief Executive of the Bureau of Health Information. She has 20 years of senior management experience measuring, monitoring and reporting on the performance of healthcare systems in Australia and internationally.
Lisa Corscadden is a senior researcher at the Bureau of Health Information. She has experience in healthcare research in Australia and Canada, with an interest in measuring equity in healthcare.
Lilian Daly is the Lead for Strategy and Engagement at the Bureau of Health Information. She holds a Master’s degree in public health from the University of New South Wales and has extensive experience as a healthcare clinician, researcher and educator.
Hilary is our Senior Director, Communications and Strategic Relations. She has extensive experience in developing policy and strategy around the role of information in improving healthcare.
Renee Carter is a former senior analyst at the Bureau of Health Information. She holds a Masters degree in health and social policy from the London School of Economics and a Doctorate in epidemiology from McGill University.
Jean-Frederic is the former Chief Executive of BHI. He is now Chief Executive of the Agency for Clinical Innovation.
Kim is the former Senior Director, Performance Measurement & Reporting at BHI. She has extensive experience in health services research in Australia and internationally.