Targeting zero, the review of hospital safety and quality assurance in Victoria

by Stephen Duckett


Remarks made by Stephen Duckett at the release of a report commissioned by the Minister for Health following the discovery of a cluster of potentially avoidable perinatal deaths at Djerriwarrh Health Services. 

We’ve used strong language in our report, and that was for a reason.

When my daughter was born, I cried with joy. I cannot imagine what it would be like to have your baby die. I cannot imagine the grief of parents on being told that their baby’s death was potentially avoidable.

My contribution to our report was written in that context. I wanted to approach this report with the view that Victoria could learn from that terrible tragedy at Bacchus Marsh Hospital.

Overall, Victoria has a great health system. We are world class in biomedical research, and exceptionally strong in clinical research too. The care that most Victorians get in our hospitals- public and private – is excellent.

But things go wrong, too frequently in my opinion. We have to have a system which helps us learn from those unhappy events.

We consulted hundreds of people in our review, and there was overwhelming support for the directions that we outlined. Clinicians are crying out for more opportunities to contribute their insights. Boards are asking for more help in the challenges they have of overseeing quality and safety in their hospitals.

No hospital is an island. Managers and clinicians want better ways of learning from each other so each hospital doesn’t have to reinvent the safety and quality wheel.

Victoria has demonstrably and unequivocally the most efficient public hospital system in the country. When I asked people about comparative quality they told me Queensland was best on tracking quality and safety, and learning from that, South Australia has the best incident reporting system, New South Wales the best on engagement and improvement. Victoria is a long way behind those states.

This report is about leap frogging those states. This report is about trying to make Victoria demonstrably and unequivocally the best in terms of safety and quality.

The report is long, with many recommendations. We didn’t paper over the problems we saw. But in my view, if you are to fix a problem, you have to acknowledge it. This is what we did. There is no quick fix to the problems we identified; we are on about serious change and embedding it. That’s why we had so many recommendations across so many areas.

I’d like to thank the Premier, the Ministers and the Secretary for picking up the challenge that we presented to them. The government’s response is all I could hope for and positions us really well for the future.

Dr Duckett was the chair of the review.