Lessons from Bacchus Marsh

by Stephen Duckett

Published by Medical Journal of Australia – Insight, Monday 14 March

The tragic events at Bacchus Marsh Hospital, where seven babies died avoidable deaths in 2013 and 2014, were an unmistakeable wake-up call for the Victorian health system.

Review of the events at Bacchus Marsh has shown that serious safety and quality issues were not identified by the hospital’s management or known to the Department of Health and Human Services until it was far too late. Instead, the hospital was fully accredited and was receiving excellent performance scores under the Department’s performance monitoring framework.

Something was obviously awry.

The Department commissioned an immediate external review of how it handled this issue, which reported late last year. Victorian Health Minister Jillian Hennessy has now also asked the Department to commission another review, looking at the broader issues of how governance of safety and quality of hospital care in Victoria can be improved. I chair that review.

The Bacchus Marsh tragedy calls into question whether existing systems and processes are fit for purpose. As it stands, serious safety and quality issues were not being identified. Hospital performance was opaque to those responsible for monitoring it, and there were clear gaps in accountability.

Reducing the likelihood of another Bacchus Marsh will require much greater oversight of safety and some tightening of accountability arrangements for hospitals.

Other states do hospital quality monitoring quite differently. Queensland uses a statistical process control system to monitor trends in key measures of outcomes of care.

New South Wales has established separate specialist organisations to lift the profile of quality improvement and safety monitoring across the state. South Australia has a state-of-the-art incident monitoring system. All these states provide much greater levels of support for safety improvement than Victoria does.

Other countries also do things differently. In England, patients undergoing some procedures (such as hip replacements) are asked before and after surgery about their level of pain and discomfort – the common reasons for presenting to a surgeon – so that their experience can be tracked using measures which are meaningful to them. Hospitals’ average performance on these measures can also be tracked and is made available publicly. Much more information is also available to the public in the United States about a hospital’s performance on both process and outcomes of care than is available in Australia.

Victoria clearly has room to improve.

Safety and quality is not a problem we can afford to neglect. It costs lives and livelihoods, and it adds hundreds of millions of dollars to the cost of running the hospital system. In a time of budget pressures, we should be pursuing improvement as urgently as ever.

More important than dollars is duty. Victorian legislation charges hospital executives, boards, the Department and its Secretary with responsibility for ensuring hospitals are monitoring and improving the quality of care. People therefore expect to be able to go to hospital knowing that systems are in place to minimise the risk of things going wrong and, if they do, ensure that lessons will be learned so that the same problems don’t occur again. This is something they have legal assurance of, and indeed deserve.

The job of the current review is to set a new path for improvement in quality and safety of care. That path has to start with looking at how to involve clinicians in the process of improving quality and safety. In South Australia and Queensland, “clinical senates” have been established to provide a statewide clinician voice to improve clinical engagement. NSW has more than 1000 clinicians engaged in statewide clinical improvement activities through the work of clinical networks. The Victorian review needs to address how to foster a culture of continuous improvement and clinical excellence in the health sector.

The Bacchus Marsh tragedy shows that early warning signs weren’t picked up and acted upon soon enough. More needs to be done on strengthening oversight of both safety issues and clinical governance by the Department, so that warning signs are detected and acted upon in a timely manner.

The other side of the safety and quality governance equation also needs to be looked at. Clinical governance of hospitals needs to be improved, so that the public can be confident that all hospitals – big and small, public and private – are delivering safe care.

Finally, we need to improve transparency within the health sector, so that communities can verify that their local hospital is rapidly identifying and rectifying important defects in care when they arise.

These are big challenges. But the public expects to be able to go to hospital knowing that systems are in place to minimise the risk of things going wrong and, if they do, lessons will be learned so that the same problems don’t occur again. It is the job of the review to make recommendations to give the public confidence that this is what happens in Victoria. The review has issued a discussion paper about the review and welcomes input from the public and health care staff about what needs to be done to improve safety and quality of care.