Article

Lessons from the Inquiry into Obstetrics and Gynaecology Services at King Edward Memorial Hospital 1990-2000

Authors:
To read the full-text of this research, you can request a copy directly from the authors.

Abstract

The Douglas Inquiry investigated the Obstetrics and Gynaecological services at King Edward Memorial Hospital from 1990-2000. Performance deficiencies were identified at state, board and hospital level contributing to poor outcomes for women, babies and families. The Inquiry raises important issues about clinical governance, leadership and culture, accountability and responsibility, safety and quality systems, staff support and development, and concern for patients and their families. The King Edward, Bristol and Royal Melbourne Hospital inquiries reveal important similarities and key lessons for governments, health care leaders and providers. The health care industry must ensure effective clinical governance supporting a culture of inquiry and open disclosure, and must build rigorous systems to monitor and improve health care safety and quality.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... The wide-ranging Douglas Inquiry, as it became known, revealed serious medical errors producing significant harm to women and babies, many of whom had died as a result (Douglas et al., 2001). Although medical critics criticized its "accusatory, blame-oriented" approach to some senior medical staff (McLean & Walsh, 2003), its lengthy report documented longstanding patterns of institutionalised mismanagement-lack of effective auditing and clinical accountability, internal conflicts between medical powerholders, shortages of qualified medical staff especially after hours, and inadequate supervision of junior medical staff (McLean & Walsh, 2003). The findings on some 800 clinical cases, which were suppressed for an inordinate time (Mooney, 2007), apparently due to medical and political pressure, are not actually my focus here though they record a sorry story. ...
... The wide-ranging Douglas Inquiry, as it became known, revealed serious medical errors producing significant harm to women and babies, many of whom had died as a result (Douglas et al., 2001). Although medical critics criticized its "accusatory, blame-oriented" approach to some senior medical staff (McLean & Walsh, 2003), its lengthy report documented longstanding patterns of institutionalised mismanagement-lack of effective auditing and clinical accountability, internal conflicts between medical powerholders, shortages of qualified medical staff especially after hours, and inadequate supervision of junior medical staff (McLean & Walsh, 2003). The findings on some 800 clinical cases, which were suppressed for an inordinate time (Mooney, 2007), apparently due to medical and political pressure, are not actually my focus here though they record a sorry story. ...
... While I cannot explore the extensive evidence or politics of the Douglas Inquiry further here, it paints a powerful picture of how the senior KEMH obstetricians shaped a collective, even delusional, occupational culture. On the basis of an array of self-interested motivations, they argued that at the KEMH, they offered a "world class" service (McLean & Walsh, 2003). In effect, if not in individual intent, such hubris and lack of accountability seriously undermined their proclaimed commitment to the health of mothers and babies. ...
Article
Full-text available
Abstract Implementation of maternity reform agendas remains limited by the dominance of a medical rather a social model of health. This paper considers group prenatal care as a complex health intervention and explores its potential in the socially divided, post-conflict communities of Northern Ireland. Using qualitative inquiry strategies, we sought key informants' views on existing prenatal care provision and on an innovative group care model (CenteringPregnancy®) as a social health initiative. We argue that taking account of the locally specific context is critical to introducing maternity care interventions to improve the health of women and their families and contribute to community development.
... The wide-ranging Douglas Inquiry, as it became known, revealed serious medical errors producing significant harm to women and babies, many of whom had died as a result (Douglas et al., 2001). Although medical critics criticized its "accusatory, blame-oriented" approach to some senior medical staff (McLean & Walsh, 2003), its lengthy report documented longstanding patterns of institutionalised mismanagement-lack of effective auditing and clinical accountability, internal conflicts between medical powerholders, shortages of qualified medical staff especially after hours, and inadequate supervision of junior medical staff (McLean & Walsh, 2003). The findings on some 800 clinical cases, which were suppressed for an inordinate time (Mooney, 2007), apparently due to medical and political pressure, are not actually my focus here though they record a sorry story. ...
... The wide-ranging Douglas Inquiry, as it became known, revealed serious medical errors producing significant harm to women and babies, many of whom had died as a result (Douglas et al., 2001). Although medical critics criticized its "accusatory, blame-oriented" approach to some senior medical staff (McLean & Walsh, 2003), its lengthy report documented longstanding patterns of institutionalised mismanagement-lack of effective auditing and clinical accountability, internal conflicts between medical powerholders, shortages of qualified medical staff especially after hours, and inadequate supervision of junior medical staff (McLean & Walsh, 2003). The findings on some 800 clinical cases, which were suppressed for an inordinate time (Mooney, 2007), apparently due to medical and political pressure, are not actually my focus here though they record a sorry story. ...
... While I cannot explore the extensive evidence or politics of the Douglas Inquiry further here, it paints a powerful picture of how the senior KEMH obstetricians shaped a collective, even delusional, occupational culture. On the basis of an array of self-interested motivations, they argued that at the KEMH, they offered a "world class" service (McLean & Walsh, 2003). In effect, if not in individual intent, such hubris and lack of accountability seriously undermined their proclaimed commitment to the health of mothers and babies. ...
Article
Full-text available
Recent quality and safety discourse stresses locating "human errors and mistakes" within an institutional framework. I go further to contend that, in spite of well-meaning individual practitioners, aspects of a powerful, self-interested obstetric professional culture pose a major barrier to quality childbirth care. Using my analysis, I contrast the profession's "knightly" self-image with critical scholarship, and it examine evidence given to public inquiries into obstetric misdemeanors and mistakes in Australia, England, and Ireland. Policy incentives to reform maternity care need to go beyond technical auditing measures to foster collaboration, social as well as institutional accountability, and critical self-reflection within the obstetric profession.
... It has been suggested that the level of surgical supervision in Australia might be low. [1][2][3] The Australian health-care study 2 in 1995 showed that 16.6% of all hospital admissions were associated with an adverse event and half of these were surgical. Issues with knowledge-based errors and inexperience were raised, with highly preventable adverse events being more likely associated with decision making rather than procedures. ...
... Clinical errors were found in 47% of cases in the King Edward Memorial Hospital Inquiry. 3 Inadequate consultant supervision was identified as a major issue. It was suggested that appropriate supervision could have reduced adverse events. ...
Article
In this study, the Australian and New Zealand Audit of Surgical Mortality evaluated the effect of operative supervision on certain post-operative outcomes in the surgical death subset. This retrospective cohort study was based upon mortality data collected in 2009 which included 1673 patients who died and had surgery within 30 days of death or during the last admission. Cases were divided into three groups: consultant not supervising (group NS), consultant supervising (group S) and consultant performing the operation (group C). A comparison was done nationally and between participating states in Australia. Certain post-operative outcomes were compared between the three groups as well as between elective and emergency operations. There were significant variations in the levels of operative supervision among states in Australia. Group NS (n = 468) generally had more favourable post-operative outcomes than group S (n = 147) and group C (n = 1058), with post-operative complication rates of 24.8%, 37.4% and 40.9% for groups NS, S and C, respectively. The level of operative supervision in emergency operations was half that of elective operations. Nevertheless, the post-operative complications rate was significantly lower in emergency operations (30.6%) compared with elective operations (64.4%). The same trend was seen with clinical management deficiencies and unplanned return to theatre. Operative supervision in emergency setting within Australian hospitals appears to be potentially inadequate. However, the available data suggest that unsupervised surgery did not result in worse post-operative outcomes. In appropriately selected cases, the data support surgical registrars performing surgery without consultant supervision.
... There were no significant changes in any of the outcome criteria in the metropolitan area. During the study period, there were major changes in antenatal and intrapartum management in the metropolitan area as a result of the inquiry into obstetric and gynaecological services at KEMH 1990-2000 (Western Australian Department of Health 2001), leading to significant improvements in all areas of intrapartum management (McLean and Walsh 2003) in the only tertiary referral hospital in WA after its release in November 2001. At the same time, there have been increasing workforce problems with shortage of obstetricians, GP obstetricians, midwives and neonatal nurses across the state but especially in the R&R areas (Perinatal and Infant Mortality Committee 2007). ...
Article
Full-text available
The objective of this study was to determine the effect of a multi-professional outreach obstetric training programme on perinatal and neonatal outcomes. This was a retrospective comparison of 5-min low Apgar scores, stillbirth, perinatal death and moderate/severe hypoxic ischaemic encephalopathy rates in 127,753 infants born in Western Australia before and after the introduction of training in rural and remote areas. Following the introduction of the training programme, there was a highly significant (p = 0.003) decrease in the rate of infants born with low 5-min Apgar scores (from 20.4 to 15.4/1,000 live births). While the changes in the other three outcomes were not significant, all three demonstrated a trend for improvement in the intervention area. This is the second study of an educational intervention in obstetrics to demonstrate improvement in neonatal outcome and the first to be associated with a decrease in caesarean sections.
... For example, a survey of more than 43 000 nurses in five countries found that the current nursing shortage and decreasing job satisfaction was linked to uneven quality of care, medical errors and adverse patient outcomes ( Aiken et al., 2001), with nurses regularly reporting that the quality of healthcare services were increasingly compromised as a result of system reform ( Greenglass and Burke, 2001). At the same time, there has been considerable worldwide concern about hospital performance in patient safety and quality ( Baker and Flintoff, 2004; Committee on Quality of Healthcare in America, 2001;McLean and Walsh, 2003) with evidence that many hospitals have not been successful in achieving acknowledged best practice in quality healthcare delivery (Dwyer and Leggat, 2002;Ibrahim and Majoor, 2002;OECD, 2004). ...
Article
Objective: Recent health system enquiries and commissions, including the National Health and Hospital Reform Commission, have promoted clinical engagement as necessary for improving the Australian healthcare system. In fact, the Rudd Government identified clinician engagement as important for the success of the planned health system reform. Yet there is uncertainty about how clinical engagement is understood in health policy and management. This paper aims to clarify how clinical engagement is defined, measured and how it might be achieved in policy and management in Australia. Methods: We review the literature and consider clinical engagement in relation to employee engagement, a defined construct within the management literature. We consider the structure and employment relationships of the public health sector in assessing the relevance of this literature. Conclusions: Based on the evidence, we argue that clinical engagement is similar to employee engagement, but that engagement of clinicians who are employees requires a different construct to engagement of clinicians who are independent practitioners. The development of this second construct is illustrated using the case of Visiting Medical Officers in Victoria. Implications: Antecedent organisational and system conditions to clinical engagement appear to be lacking in the Australian public health system, suggesting meaningful engagement will be difficult to achieve in the short-term. This has the potential to threaten proposed reforms of the Australian healthcare system.
... For example, a survey of more than 43 000 nurses in five countries found that the current nursing shortage and decreasing job satisfaction was linked to uneven quality of care, medical errors and adverse patient outcomes (Aiken et al., 2001), with nurses regularly reporting that the quality of healthcare services were increasingly compromised as a result of system reform (Greenglass and Burke, 2001). At the same time, there has been considerable worldwide concern about hospital performance in patient safety and quality (Baker and Flintoff, 2004; Committee on Quality of Healthcare in America, 2001;McLean and Walsh, 2003) with evidence that many hospitals have not been successful in achieving acknowledged best practice in quality healthcare delivery (Dwyer and Leggat, 2002;Ibrahim and Majoor, 2002;OECD, 2004). ...
Article
This study investigates the mediation effects of the four components of psychological empowerment on the relationship between high performance work systems (HPWS) and perceptions of patient care quality among hospital employees. To test this relationship 541 hospital employees in a large regional Australian health service were surveyed. Regression analysis findings demonstrated that psychological empowerment fully mediated the relationship between HPWS and the perception of the quality of patient care. Three of the four individual components of psychological empowerment — autonomy, competence and meaning — fully mediated the relationship between HPWS and the perception of quality of care; the fourth — impact — was non-significant. This study demonstrates the need to recognise that the quality of patient care is influenced not only by clinicians but also by allowing all hospital employees to exercise concern through their work. Healthcare managers need to focus on ensuring HRM strategy, policy and processes support the implementation of HPWS at the unit level.
... For example, a survey of more than 43 000 nurses in five countries found that the current nursing shortage and decreasing job satisfaction was linked to uneven quality of care, medical errors and adverse patient outcomes (Aiken et al., 2001), with nurses regularly reporting that the quality of healthcare services were increasingly compromised as a result of system reform (Greenglass and Burke, 2001). At the same time, there has been considerable worldwide concern about hospital performance in patient safety and quality (Baker and Flintoff, 2004; Committee on Quality of Healthcare in America, 2001;McLean and Walsh, 2003) with evidence that many hospitals have not been successful in achieving acknowledged best practice in quality healthcare delivery (Dwyer and Leggat, 2002;Ibrahim and Majoor, 2002;OECD, 2004). ...
Article
Acute skills shortages increasingly affect governments’ capacity to conduct policy. Yet, responses to the challenge remain patchy. In Australia, as elsewhere, the public service is facing growing divergence between its own urge to undertake systematic workforce planning and slow, inadequate or inexistent response by most of its line agencies. This article analyses recent survey, audit and administrative data to uncover the roots of this puzzle. Current trends are evaluated and illustrated through five case studies, which suggest important roles for leadership commitment, organisational culture, and the geostrategic exposure of organisations.
... Governments, health service boards, health care leaders, managers and clinicians have the opportunity to learn from the Douglas Inquiry's lessons and lead the way to improved hospital systems and better, safer patient care'' [9]. ...
Article
There are significant problems to consider when we reflect on “Standards for Gynecologic Surgery.” Surely most professional standards are already in place, or are they? Are standards already available, locally, nationally, or internationally? Where those standards are not already available will it be possible set new standards for the multiplicity of operative interventions, performed by an array of trainees, specialists, and colleagues many of whom are outside of our remit and spread over the continents? If we do set standards how do we audit outcomes to gynecologic surgery and insure that the standards are being complied with? How do we tutor our trainees effectively and also insure that established specialists retain their skill base, are up-to-date, and compliant with continuing medical education? It is important to realize that the success or failure of a modern surgical investigation or procedure will now be judged not on the pure surgical outcome alone, but will also need to reflect patient focus through excellence in the areas of communication, patient information, informed consent and confidentiality. The accessibility to services, appropriate environment, and processes being offered by trained and competent staff members—who are supervised when required—should all be included in audits of outcomes set against agreed auditable standards.
... During this period, the hospital regularly received ACHS accreditation focused on the nominal existence of structures and processes. 12 In 1999, a newly appointed Chief Executive Officer (CEO), Michael Moodie, wrote to the Metropolitan Health Service Board providing evidence of major quality and safety deficiencies. In doing so, as the investigation expressly recognised, the CEO was joining the ranks of whistleblowers. ...
Article
Full-text available
The protracted and costly investigations into Camden and Campbelltown hospitals (New South Wales), The Canberra Hospital (Australian Capital Territory), and King Edward Memorial Hospital (Western Australia) recently uncovered significant problems with quality and safety at these institutions. Each investigation arose after whistleblowers alerted politicians directly, having failed to resolve the problems using existing intra-institutional structures. None of the substantiated problems had been uncovered or previously resolved by extensive accreditation or national safety and quality processes; in each instance, the problems were exacerbated by a poor institutional culture of self-regulation, error reporting or investigation. Even after substantiation of their allegations, the whistleblowers, who included staff specialists, administrators and nurses, received little respect and support from their institutions or professions. Increasing legislative protections indicate the role of whistleblowers must now be formally acknowledged and incorporated as a "last resort" component in clinical-governance structures. Portable digital technology, if adequately funded and institutionally supported, may help to transform the conscience-based activity of whistleblowing into a culture of self-reporting, linked to personal and professional development.
... Limited researches are in combining these two aspects. McLean and Walsh (2003) stated that there have been considerable worldwide researches about hospital performances in patient safety and quality. Hospitals have not been successful in achieving acknowledged best practices with evidence (Dwyer and Leggat, 2002). ...
Article
Full-text available
Organizational activities are based on key service lines, customers, resources, and learning & growth. These four aspects that are based on the balanced scorecard (BSC) are used for understanding performance of an organisation. Customers are patients who get treatment in different key disease service lines. Patient satisfaction represents degree to which they perceive that their needs are fulfilled in different key disease service lines. Objectives of this study are to determine factors affecting performance of PHSOs; to know factors influencing on patient satisfaction in public health service organizations and to determine the relationship between performance of PHSOs and patient satisfaction. 100 employees were selected as sample size for answering performance. 100 patients were also selected as sample size for answering patient satisfaction in this study. Questionnaires were used to collect responses from employees and patients. Primary data have been collected during the period of first quarter of 2013. Collected questionnaires have been analysed by factor analysis, correlation and regression analysis. Study found that patient, key service line, learning & growth and resource have been identified as factors influencing the performance of public health service organizations. Patient satisfaction is determined by human element, non-human element and servicescapes factors. Relationship between performance of public health service organization and patient satisfaction are tested by correlation and regression followed by factor analysis. Pearson correlation value is higher than 0.662. This indicates that performance of PHSOs is correlated with patient satisfaction. Value of R is 0.662. There is a high strength of association between performance of PHSO and patient satisfaction. Value of R square is 0.438. There is a moderate degree of association between performance of PHSO and patient satisfaction. Value of adjusted R square is 0.432. There is a moderate degree of association between performance of PHSO and patient satisfaction. In this study, non-standardized beta coefficient for corporate performance is 0.544. When there is an increase in corporate performance by one unit patient satisfaction increases by 0.544 unit. Patient satisfaction [Ῠi] = 1.460 + .5443 * corporate performance.
Article
The extraordinary (unplanned) review of clinical privileges is the means by which an organisation can manage specific complaints about individual practitioners' clinical competence that require immediate investigation. To date, the extraordinary review of clinical privileges for doctors and dentists has not been the subject of much research and there is a pressing need for the evaluation and review of how different legislated and non-legislated administrative processes work and what they achieve. Although it seems a fair proposition that comprehensive processes for the evaluation of the clinical competence of doctors and dentists may improve the overall delivery of an organisation's clinical services, in fact, little is known about the relationship between the safety and quality of specific clinical services, procedures and interventions and the efficiency or effectiveness of established methodologies for the routine or the extraordinary review of clinical privileges. The authors present a model of a structured approach to the extraordinary review of clinical privileges within a clinical governance framework in the Australian Capital Territory. The assessment framework uses a primarily qualitative methodology, underpinned by a process of systematic review of clinical competence against the agreed standards of the CanMEDS Physician Competency Framework. The model is a practical, working framework that could be implemented on a hospital-, area health service- or state- and territory-wide basis in any other Australian jurisdiction.
Article
Full-text available
Building a safety culture is an important part of improving patient care. Measuring perceptions of safety climate among healthcare teams and organisations is a key element of this process. Existing measurement instruments are largely developed for secondary care settings in North America and many lack adequate psychometric testing. Our aim was to develop and test an instrument to measure perceptions of safety climate among primary care teams in National Health Service for Scotland. Questionnaire development was facilitated through a steering group, literature review, semistructured interviews with primary care team members, a modified Delphi and completion of a content validity index by experts. A cross-sectional postal survey utilising the questionnaire was undertaken in a random sample of west of Scotland general practices to facilitate psychometric evaluation. Statistical methods, including exploratory and confirmatory factor analysis, and Cronbach and Raykov reliability coefficients were conducted. Of the 667 primary care team members based in 49 general practices surveyed, 563 returned completed questionnaires (84.4%). Psychometric evaluation resulted in the development of a 30-item questionnaire with five safety climate factors: leadership, teamwork, communication, workload and safety systems. Retained items have strong factor loadings to only one factor. Reliability coefficients was satisfactory (α = 0.94 and ρ = 0.93). This study is the first stage in the development of an appropriately valid and reliable safety climate measure for primary care. Measuring safety climate perceptions has the potential to help primary care organisations and teams focus attention on safety-related issues and target improvement through educational interventions. Further research is required to explore acceptability and feasibility issues for primary care teams and the potential for organisational benchmarking.
Article
Full-text available
To seek public opinion on the reporting of medical errors and the anonymity of healthcare workers who report medical errors. A random, representative survey of 2005 South Australians in April 2002, using telephone interviews based on a vignette provided. When a medical error occurs (i) whether the incident should be reported, and (ii) whether the report should disclose the healthcare worker's identity. (i) Most respondents (94.2%; 95% CI, 93.0%-95.2%) believed healthcare workers should report medical errors. (ii) 68.0% (95% CI, 65.5%-70.5%) of those in favour of reporting believed the healthcare worker should be identified on the report, while 29.2% (95% CI, 26.7%-31.7%) favoured anonymous reporting. Most respondents believed that, when a healthcare worker makes an error, an incident report should be written and the individual should be identified on the report. Respondents were reluctant to accept healthcare worker anonymity, even though this may encourage reporting.
Article
The protracted and costly investigations into Camden and Campbelltown hospitals (New South Wales), The Canberra Hospital (Australian Capital Territory), and King Edward Memorial Hospital (Western Australia) recently uncovered significant problems with quality and safety at these institutions. Each investigation arose after whistleblowers alerted politicians directly, having failed to resolve the problems using existing intra-institutional structures. None of the substantiated problems had been uncovered or previously resolved by extensive accreditation or national safety and quality processes; in each instance, the problems were exacerbated by a poor institutional culture of self-regulation, error reporting or investigation. Even after substantiation of their allegations, the whistleblowers, who included staff specialists, administrators and nurses, received little respect and support from their institutions or professions. Increasing legislative protections indicate the role of whistleblowers must now be formally acknowledged and incorporated as a "last resort" component in clinical-governance structures. Portable digital technology, if adequately funded and institutionally supported, may help to transform the conscience-based activity of whistleblowing into a culture of self-reporting, linked to personal and professional development.
Article
Full-text available
An inappropriate culture is often presented as the reason why hospitals throughout the world have been unable to achieve best practice. Many have concluded that the organizational culture of hospitals limits the ability of these organizations to improve performance, particularly in relation to improving quality and safety. Establishment of a "better" culture is often presented as the resolution to quality, safety, financial and productivity issues in hospitals. Our research indicates that certain management conditions are required before culture change can be contemplated. This paper suggests that we have underestimated the importance of people management in improving practice within hospitals, with the three most important aspects being the development of teamwork, performance management and sophisticated training. We present evidence of the potential contribution good people management can make to high performance, and argue that better people management is a cause, not an outcome, of cultural change.
Article
When will Australians be able to count on receiving health care that is safe?
Article
Since the 1960s, Australian society and the medical profession have undergone enormous change. Our society has moved from a relatively homogeneous and conservative community, supported by limited government services, to one that is multicultural, focused on the individual and consumerism, and supported by extensive government programs, with health care a top public and political priority. A defining feature of contemporary society is its mistrust of institutions, professionals, public servants and politicians. The medical profession has changed from a cohesive entity, valuing generalism and with limited specialisation, to one splintered by ultra-specialisation and competing professional agendas. The medical workforce shortage and efforts to maintain the safety and quality of health services are putting acute pressure on the profession. Task transfer or role substitution of medical services is mooted as a potential solution to this pressure. This has the potential to drastically transform the profession. How task transfer will evolve and change medicine depends on the vision and leadership of the profession and a flexible pragmatism that safeguards quality and safety and places patient priorities above those of the profession.
Article
Full-text available
Mishandled concerns about clinical standards resulted in whistleblowing in four Australian hospitals. Official inquiries followed with recommendations to improve patient safety. In the aftermath of the inquiries, common themes included loss of trust in management and among clinical colleagues, and loss of trust from patients and the community. Without first rebuilding trust, staff will not report mistakes or other concerns about safety. Successful implementation of patient safety procedures requires policies to stress the professional duty of staff to report concerns about colleagues when they believe there is a risk to patients.
Article
The promotion of safe sports participation has become a public health issue due to rising obesity rates and the potential for parental concerns about safety to inhibit sports participation. The safety of Australian football and its elite game, the Australian Football League (AFL), is often the focus of media commentary. Participation in the modified version of the game (Auskick) has been shown to be safer but by the time children reach the under-15 age group, adult rules are in place and the umbrella of safety provided by modified rules is gone. Figures released recently by the AFL suggest that injury rates at the elite-level are at an historical low, but equivalent information for the more than 400,000 non-elite participants is not available. Published literature related to preventing injuries in Australian football highlights a significant knowledge gap with respect to the aetiology of injuries in non-elite participants and only a very small evidence base for prevention of injuries in this sport. Gains in reducing the public health impact of football injuries, and injury-related barriers to Australian football participation, will only come from substantial investment in large-scale trials at the non-elite level, and a co-ordinated and multidisciplinary approach to dealing with safety and injury issues across all levels of play. Active and committed collaboration of key stakeholders such as government health agencies, peak sports bodies, sports administrators, clinicians, researchers, clubs, coaches and the participants themselves will be necessary.
Article
Full-text available
A group of consumers of private hospital services and their carers collaborated with staff of a Melbourne private hospital and with industry representatives to develop a consumer-driven performance report on cardiac services. During the development process participating consumers identified situational and structural barriers to their right to be informed of costs, to choice and to quality care. Their growing appreciation of these barriers led them to a different perspective on performance reporting, which resulted in their redirecting the project. The consumer participants no longer wanted a performance report that provided comparative quantitative data. Instead they designed a report that outlined the structures, systems and processes the hospital had in place to address the quality and safety of services provided. In addition, consumer participants developed a decision support tool for consumers to use in navigating the private health care sector. The journey of these consumers in creating a consumer driven performance report for a private hospital service may assist those responsible for governance of Australia's health system in choosing appropriate strategies and mechanisms to enhance private hospital accountability. The situational and institutional industry barriers to choice, information and quality identified by these consumers need to be addressed before public performance reporting for private hospitals is introduced in Australia.
Article
This study aimed to build on the increasing evidence of a link between good people management practice, and organizational and patient outcomes in public health care to document the important human resource management practices in our hospitals. The design included large scale survey of hospital managers' perceptions of the use of human resource management practices. The questionnaire included Human resource management (HRM) measures and additional questions related to the Australian hospital accreditation standards. Data were collected in December 2003 until April 2004 from a total sample of 92 hospitals/hospital organizations from the State of Victoria, Australia. The participants were Chief Executive Officers, Human Resource Directors and two other senior managers of the hospital organizations were invited to complete the questionnaire. There were no interventions. The main outcome measure, one-way analysis of variance was used to determine differences in the perceptions of the three groups of managers' concerning the use of HRM practices. Frequency and descriptive statistics were used to determine use of HRM practices. A 67% response rate enabled us to document human resource management practices in Victorian hospitals. The respondents reported limited strategic and organizational HRM. This study found limited evidence of sophisticated HRM practices among hospitals and hospital organizations in the State of Victoria, Australia. Despite the increasing evidence of a relationship among effective HRM and health-care outcomes, these hospitals reported limited performance management, training and development, and employee empowerment and decision-making. The authors suggest that it is unlikely that attempts to improve patient safety in this sector will be successful until the deficits in HRM are addressed.
Article
This aim of this study was to investigate the interactive effects of psychological empowerment and job satisfaction on the relationship between high-performance work systems (HPWS) and nurses' perceptions of the quality of patient care they provide. Studies of high-performing organizations in a variety of industries have consistently reported a positive relationship between HPWS and performance outcomes. Although many of these studies have been conducted in manufacturing, similar findings of a positive correlation between aspects of HPWS and improved patient outcomes have been reported in international health care studies. We used regression analysis with tests of mediation and moderation to analyze survey responses collected in March 2008 of 201 nurses in a large regional Australian health service. Psychological empowerment fully mediated the relationship between HPWS and perceptions of quality of patient care. Job satisfaction moderated the relationship between HPWS and perceptions of quality of patient care. Hospital managers should focus on promoting HPWS and ensuring that nurse unit managers have the competencies to empower and to enhance the job satisfaction of their staff.
Article
Background In Victoria, Australia, public hospitals are administered through a system of devolved governance. Overall, Victoria's public health system has a record of good performance when comparing measurable safety outcomes to the rest of Australia. However, in 2015 a cluster of preventable perinatal deaths were identified at a health service in Melbourne's outer fringes. Questions What were the factors that contributed to these preventable deaths, and what were the outcomes of the four key inquiries commissioned by the Victorian government after the identification of the cluster? What can be learnt by comparing this crisis in one Victorian health service to similar events at other health services in Australia and the United Kingdom? Methods This paper discusses the crisis at the Victorian health service and expands on the factors that contributed to the crisis, the inquiries, subsequent recommendations, and the response from the Victorian state government. Similarities between this case and others in Australia and the United Kingdom are discussed. Findings A common theme in the four inquiries into the crisis at the health service in Victoria was that inadequate clinical governance was a key factor that led to these events. As a result, a number of significant changes were implemented across the state to improve patient safety across all areas of health care. When comparing this Victorian crisis to similar events at other health services across the world, inadequate clinical governance consistently appears as a key contributing factor to poor clinical outcomes. Discussion All cases discussed had a delay in the identification of clusters of poor clinical outcomes. This was found to be a direct result of inadequate clinical governance structures at both a local and government level. Conclusion A robust clinical governance framework that is enacted at both the government and the health organisation level is essential to deliver high quality and safe patient care.
Article
Full-text available
Studies of high-performing organisations have consistently reported a positive relationship between high performance work systems (HPWS) and performance outcomes. Although many of these studies have been conducted in manufacturing, similar findings of a positive correlation between aspects of HPWS and improved care delivery and patient outcomes have been reported in international health care studies. The purpose of this paper is to bring together the results from a series of studies conducted within Australian health care organisations. First, the authors seek to demonstrate the link found between high performance work systems and organisational performance, including the perceived quality of patient care. Second, the paper aims to show that the hospitals studied do not have the necessary aspects of HPWS in place and that there has been little consideration of HPWS in health system reform. The paper draws on a series of correlation studies using survey data from hospitals in Australia, supplemented by qualitative data collection and analysis. To demonstrate the link between HPWS and perceived quality of care delivery the authors conducted regression analysis with tests of mediation and moderation to analyse survey responses of 201 nurses in a large regional Australian health service and explored HRM and HPWS in detail in three casestudy organisations. To achieve the second aim, the authors surveyed human resource and other senior managers in all Victorian health sector organisations and reviewed policy documents related to health system reform planned for Australia. The findings suggest that there is a relationship between HPWS and the perceived quality of care that is mediated by human resource management (HRM) outcomes, such as psychological empowerment. It is also found that health care organisations in Australia generally do not have the necessary aspects of HPWS in place, creating a policy and practice gap. Although the chief executive officers of health service organisations reported high levels of strategic HRM, the human resource and other managers reported a distinct lack of HPWS from their perspectives. The authors discuss why health care organisations may have difficulty in achieving HPWS. Leaders in health care organisations should focus on ensuring human resource management systems, structures and processes that support HPWS. Policy makers need to consider HPWS as a necessary component of health system reform. There is a strong need to reorient organisational human resource management policies and procedures in public health care organisations towards high performing work systems.
Article
Improved leadership and recognising each others' humanity are necessary for true health care reform.
Article
Full-text available
To describe the engagement of health service boards with quality-of-care issues and to identify factors that influence boards' activities in this area. We conducted semistructured interviews with 35 board members and executives from 13 public health services in Victoria, Australia. Interviews focused on the role currently played by boards in overseeing quality of care. We also elicited interviewees' perceptions of factors that have influenced their current approach to governance in this area. Thematic analysis was used to identify key themes from interview transcripts. Virtually all interviewees believed boards had substantial opportunities to influence the quality of care delivered within the service, chiefly through setting priorities, monitoring progress, holding staff to account and shaping culture. Perceived barriers to leveraging this influence included insufficient resources, gaps in skills and experience among board members, inadequate information on performance and regulatory requirements that miss the mark. Interviewees converged on four enablers of more effective quality governance: stronger regional collaborations; more tailored board training on quality issues; smarter use of reporting and accreditation requirements; and better access to data that was reliable, longitudinal and allowed for benchmarking against peer organisations. Although health service boards are eager to establish quality of care as a governance priority, several obstacles are blocking progress. The result is a gap between the rhetoric of quality governance and the reality of month-to-month activities at the board level. The imperative for effective board-level engagement in this area cannot be met until these barriers are addressed.
Article
Given the universal pressures within the health and elderly care sectors for cost reduction and the need for high-quality care, the effective management of the workforce in care organizations is of critical importance. In this article, we examine the changing landscape of the health care and aged care systems and identify key challenges for the human resource management (HRM) field. We assess existing research evidence on the role of HRM and high-performance work systems in the health care sector. We also outline a number of research areas as fruitful avenues for future studies, drawing particular attention to aged care as an underresearched subsector, and immigrants as an important group of research targets. The key message of our article is that future research on HRM in the care sector has much to gain by adopting an interdisciplinary, multilevel, and multistakeholder approach. More cross-sectoral and cross-country comparative studies of HRM in health care and other care work are also needed to shed light on how policy orientations, institutional arrangements, social norms, and cultural traditions influence care regimes across different societies, and to encourage the sharing of learning across societies. © 2015 Wiley Periodicals, Inc.
Article
Responding to the public concern caused by recent hospital scandals and accounts of unintended harm to patients, this author draws on her experience of analysing the health care systems of over a dozen countries and examines whether greater regulation has increased patient safety and health care quality. The book adopts a new approach to mapping developments in health care systems in Europe, North America and Australia and pieces together evidence of which regulatory strategies and mechanisms work well to ensure safer patient care. It identifies the regulatory bodies, the regulatory principles and the implementation strategies adopted to improve governance in health care systems and suggests a conceptual framework for responsive regulation. The book will be of interest to government actors, health care professionals and medico-legal scholars.
Article
Background: A number of adverse events in Australia and overseas have highlighted the need to examine the workplace culture in the maternity environment. Little attention has been paid to the midwifery workplace culture in Australia. Aim: The study aimed to explore the midwifery workplace culture from the perspective of midwives themselves. Methods: A qualitative descriptive design was used. Group and individual interviews were undertaken of urban, regional and rural-based midwives in Australia. Data were analysed thematically. Findings: The study showed that both new and experienced midwives felt frustrated by organisational environments and attitudes, and expressed strategies to cope with this. Five themes were identified from the data. These were: Bullying and resilience, Fatigued and powerless midwives, Being 'hampered by the environment', and The importance of support for midwifery. Discussion: The study discusses the themes in depth. In particular, discussion focusses on how midwifery practise was affected by midwives' workplace culture and model of care, and the importance of supportive relationships from peers and managers. Conclusion: This study illuminated both positive and negative aspects of the midwifery workplace culture in Australia. One way to ensure the wellbeing and satisfaction of midwives in order to maintain the midwifery workforce and provide quality care to women and their families is to provide positive workplace cultures.
Purpose Employee engagement (EE), supervisor support (SS) and interprofessional collaboration (IPC) are important contributors to patient safety climate (PSC). The purpose of this paper is to propose and empirically test a model that suggests the presence of a three-way interaction effect between EE, IPC and SS in creating a stronger PSC. Design/methodology/approach Using validated tools to measure EE, SS, IPC and PSC data were collected from a questionnaire of 250 clinical and support staff in an Australian health service. Using a statistical package (SPSS) an exploratory factor analysis was conducted. Bivariate correlations between the derived variables were calculated and a hierarchical ordinary least squares analysis was used to examine the interaction between the variables. Findings This research finds that PSC emerges from synergies between EE, IPC and SS. Modelling demonstrates that the effect of IPC with PSC is the strongest when staff are highly engaged. While the authors expected SS to be an important predictor of PSC; EE has a stronger relationship to PSC. Practical implications These findings have important implications for the development of patient safety programmes that focus on developing excellent supervisors and enabling IPC. Originality/value The authors provide quantitative evidence relating to three of the often mentioned constructs in the typology of patient safety and how they work together to improve PSC. The authors believe this to be the first empirically based study that confirms the importance of IPC as a lead marker for improved patient safety.
Purpose Building a new hospital requires a major investment in capital infrastructure. The purpose of this paper is to investigate the impact of bricks-and-mortar on patient safety culture before and two years after the move of a large tertiary hospital to a greenfield site. The difference in patient safety perceptions between clinical and non-clinical staff is also explored. Design/methodology/approach This research uses data collected from the same workforce across two time periods (2013 and 2015) in a large Australian healthcare service. Validated surveys of patient safety culture ( n =306 and 246) were analysed using descriptive and inferential statistics. Findings Using two-way analysis of variance, the authors found that perceived patient safety culture remains unchanged for staff despite a major relocation and upgrade of services and different perceptions of patient safety culture between staff groups remains the same throughout change. Practical implications A dramatic change in physical context, such as moving an entire hospital, made no measurable impact on perceived patient safety culture by major groups of staff. Improving patient safety culture requires more than investment in buildings and infrastructure. Understanding differences in professional perspectives of patient safety culture may inform organisational management approaches, and enhance the targeting of specific strategies. Originality/value The authors believe this to be the first empirically based paper that investigates the impact of a large investment into hospital capital and a subsequent relocation of services on clinical and non-clinical staff perceptions of patient safety culture.
Purpose The scientific literature evidences that the quality of care must be improved. However, little research has focused on investigating how health care managers – who are responsible for the implementation of quality interventions – define good and poor quality. The purpose of this paper is to develop an empirically informed taxonomy of quality care as perceived by US managers – named the Integrative Quality Care Assessment Tool (INQUAT) – that is grounded in Donabedian’s structure, process and outcome model. Design/methodology/approach A revised version of the critical incident technique was used to collect 135 written narratives of good and poor quality care from 74 health care managers in the USA. The episodes were thematically analyzed. Findings In total, 804 units were coded under the 135 written narratives of care. They were grouped under structure (9 percent, n=69), including organizational, staff and facility resources; process (52 percent, n=419), entailing communication, professional diligence, timeliness, errors, and continuity of care; outcomes (32 percent, n=257), embedding process- and short-term outcomes; and context (7 percent, n=59), involving clinical and patient factors. Process-related categories tended to be described in relation to good quality (65 percent), while structure-related categories tended to be associated with poor quality (67 percent). Furthermore, the data suggested that managers did not consider their actions as important factors influencing quality, but rather tended to attribute the responsibility for quality care to front-line practitioners. Originality/value The INQUAT provides a theoretically grounded, evidence-based framework to guide health care managers in the assessment of all the components involved with the quality of care within their institutions.
Article
Full-text available
Purpose: The purpose of this paper is to review the implementation of seven components of quality systems (QSs) linked with quality improvement in a sample of Australian hospitals. Design/methodology/approach: The authors completed a systematic review to identify QS components associated with measureable quality improvement. Using mixed methods, the authors then reviewed the current state of these QS components in a sample of eight Australian hospitals. Findings: The literature review identified seven essential QS components. Both the self-evaluation and focus group data suggested that none of the hospitals had all of these seven components in place, and that there were some implementation issues with those components that were in use. Although board and senior executives could point to a large number of quality and safety documents that they felt were supporting a vision and framework for safe, high-quality care, middle managers and clinical staff described the QSs as compliance driven and largely irrelevant to their daily pursuit of safe, high-quality care. The authors also found little specific training in quality improvement for staff, lack of useful data for clinicians on the quality of care they provide and confusion about how organisational QSs work. Practical implications: This study provides a clearer picture of why QSs are not yet achieving the results that boards and executives want to achieve, and that patients require. Originality/value: This is the first study to explore the implementation of QSs in hospitals in-depth from the perspective of hospital staff, linking the findings to the implementation of QS component identified in the literature.
Article
Full-text available
Following a high profile scandal relating to quality and safety of care, the health authority in the Australian state of Queensland introduced a pay for performance (P4P) component into its new hospital prospective payment system. The Clinical Practice Improvement Payment system pays hospitals for achievement of clinical process indicators. Initially the focus is on the quality of clinical processes and outcomes. Using a consensus approach involving consultation with clinicians, seven clinical indicators were adopted for 2007-2008. The first payments using pay for performance were made for work carried out up until June 2008. Although no data exist yet as to the impact of the new system, pay for performance appears to be gaining widespread, if somewhat reluctant, acceptance.
Brain death " not spotted for days Bristol unit used " out of date " operation Money came first, baby inquiry told
  • Australian Council
  • Safety Quality
  • Health In
  • Care
Australian Council for Quality and Safety in Health Care 2002, Lessons from the Inquiry in Obstetrics and Gynaecological Services at King Edward Memorial Hospital 1990-2000, July BBC 1999, The Bristol heart babies, http://news.bbc.co.uk/engl…/the_bristol_babies_inquiry/, 22 March BBC 1999, Brain death " not spotted for days ", http://news.bbc.co.uk/2/low/health/533790, 23 November BBC 1999, Bristol unit used " out of date " operation, http//news.bbc.uk/1/hi/health/background- b…/304026.stm, 25 March BBC 1999, Money came first, baby inquiry told, http//news.bbc.co.uk/1/hi/health/532123.stm, 22 November Child A and Glover P 2000, Report on the obstetrics and gynaecological services at King Edward Memorial Hospital to the Metropolitan Health Service Board, WA, April
Yes, Minister, it's a whitewash, The West Australian
  • S Cowan
Cowan S 2000, Yes, Minister, it's a whitewash, The West Australian, 25 October, p 16
Inquiry into obstetrics and gynaecological services at King Edward Memorial Hospital
  • N Douglas
  • J Robinson
  • K Fahy
Douglas N, Robinson J, Fahy K 2001, Inquiry into obstetrics and gynaecological services at King Edward Memorial Hospital, Western Australia, Nov
Moodie rejects gag contract, The Weekend Australian
  • C Egan
Egan C 2000, Moodie rejects gag contract, The Weekend Australian, 28 October, p9
Doctors no – state of health, The Weekend Australian
  • B Hickman
  • C Egan
Hickman B and Egan C 2000, Doctors no – state of health, The Weekend Australian, 28 October, p23
Why did so many babies die? Sydney Morning Herald
  • J Hills
Hills J 2000, Why did so many babies die? Sydney Morning Herald, October 8, p10
The inquiry into the management of care of children receiving complex heart surgery at the Bristol Royal Infirmary – Final Report, July UK Department of Health Learning from Bristol: The DH response to the report of the public inquiry into children's heart surgery at the Bristol Royal Infirmary
  • Kennedy
Kennedy 2001, The inquiry into the management of care of children receiving complex heart surgery at the Bristol Royal Infirmary – Final Report, July UK Department of Health 2002, Learning from Bristol: The DH response to the report of the public inquiry into children's heart surgery at the Bristol Royal Infirmary 1984-1995, Department of Health Crown Copyright.