7. Quality Programs Effectiveness, Safety, Performance

7.1 Maternity Services Enhancement Strategy

This Strategy will be implemented over a four year period with $12.9 million available in 1998 - 99, building to $16.4 million recurrent funding in 1999 - 2000.

The objectives of this major initiative are:

• To promote improvements in the continuum and quality of care available to women with differing needs for antenatal, intrapartum and postnatal care;
• To provide women with information about available options for care and information about the effectiveness of these options to enable informed decision making; and
• To improve services and health outcomes through the promotion of practice based on best available and clinical guidelines evidence and the development and implementation of performance indicators.

$9.7 million for additional postnatal care will be allocated to Networks and rural regions according to the number of births in hospitals in 1996 - 97. Part year funding amounting to $1 million will be allocated to Networks and rural regions for increased provision of antenatal care. Funds will be provided in the form of specified grants and hospitals will be required to demonstrate measurable improvement in the provision of antenatal and postnatal care. Particular attention will be given to the strategic targetting of services to women with special needs, who are at risk of poorer health outcomes, and to improving continuity of care, particularly with respect to community providers of antenatal and postnatal care and support. The performance of hospitals in improving services will be closely monitored, including through targetted patient satisfaction surveys.

Participation in antenatal care, birthing and postnatal health outcomes have been shown to be poorer for Aboriginal and Torres Strait Islander women and their babies. Under the Commonwealth Birthing Services Program in Victoria, there have been several successful pilots of antenatal and postnatal support provided by Aboriginal and Torres Strait Islander health workers in collaboration with hospitals and community medical services. However, to date there has been no recurrent source of funding to build on this work. Part year funding of $0.2 million, building to $0.6 million full year funding, will be provided to community managed aboriginal health services for community health workers to assist women and infants with antenatal, intrapartum, and postnatal care.

The Department wishes to collaborate with clinicians and health care managers; with consumers; with community providers; and with colleges and other professional organisations to improve the effectiveness of maternity care across the state over the next four years. In 1998 - 99, $2 million will be available for the investigation of effectiveness of care and evidence based practice; evaluation of models of care; costing studies; and initiatives for the provision of consumer information and improved communication between health care providers and mothers and their families. Priorities for development will be established in collaboration with stakeholders and submissions sought from a range of organisations with expertise in service delivery, strategic development, clinical research and program evaluation.

In association with the implementation of this strategy, hospitals will be required to provide additional patient level data on postnatal domiciliary care. These data will be provided at a patient level through the Agency Information Management System to allow for linking with the VIMD. Hospitals will be expected to participate and collaborate in research and evaluation conducted as part of the maternity services enhancement strategy. Allocations for maternity services have been incorporated into the modelled budgets for the Networks and notionally set for rural hospitals. Final allocations for rural hospitals will be determined by the Regional Office.

7.2 Pneumococcal Vaccination

Additional funding of $2 million will be transferred to the Public Health Division to fund pneumococcal vaccination for all Victorians aged more than 65, through their general practitioners and other providers. It is expected that this will reduce hospital emergency department attendances and demand for inpatient care, especially for those with chronic cardiovascular or pulmonary disease.

7.3 Best Practice

Many hospitals are participating either in local or national initiatives to research and encourage 'Best Practice'. The Department sees this as an important development in improving patient care. As an incentive to directly foster these elements of best practice a limited amount of funds ($0.75 million) was allocated last year. The aim was to encourage hospitals and provide models for other hospitals to meet standards beyond the current industry standards.

Projects within this Program includes an assessment of outcomes for medical and surgical management of miscarriage; a review of radiotherapy services in Victoria; research on increasing the number of organ donors; and a major stroke project.

Chest pain evaluation areas are being piloted in three major emergency departments. This is the second year of a three year pilot for which a total of $1.8 million dollars will be provided over the course of the pilot program.

The Department will continue to encourage the provision of care which is in accordance with known best practice. Limited initiative funding will be available for programs or projects that promote practical use of research evidence on effectiveness of health care. Networks and hospitals will be invited to submit suitable funding proposals for projects that promote integration of available knowledge on effectiveness into routine service delivery; improve continuity and safety of care; or improve information for consumers. Detailed information on format of submissions, eligibility criteria and external review procedures will be circulated to all Networks and hospitals in August 1998.

7.4 Infection Control

Infection control is an integral part of the day to day responsibilities of every hospital in the State. The Department will support statewide programs for monitoring, investigating outbreaks and providing expert advice on infection control. The $3 million allocated to improving infection control surveillance and practices will also be used to provide some supplementary funding to help networks and hospitals meet best practice guidelines.

Infection control processes, policies and resources were audited in all Victorian acute public hospitals in 1997 - 98. Hospitals were notified of local issues of immediate concern, identified by the Infection Control Taskforce, to be remedied by June 1998. To address longer-term issues Taskforce recommendations will be implemented in 1998 - 99. These include investigation of the feasibility of an on-line hospital infection control advisory service; establishment of an Expert Working Group to develop infection control performance indicators; and modification of the infection control survey tool with development of a timetable for re-survey of Victorian hospitals. In addition all plans submitted to the Department for major capital works, redesign or structural maintenance must include an infection control risk assessment plan.

Networks and hospitals will be asked to submit a costed infection monitoring and control plan by 30 October 1998 with a strategy for implementation which does not rely on additional recurrent financial assistance to maintain appropriate standards and practices.

7.5 Clinical Risk Management

There are currently four pilot Clinical Risk Management projects. There will be a formal evaluation of these pilots in 1998 - 99. The evaluation will focus on the value of various methods for collecting and analysing clinical incident information, such as retrospective review of medical records, standardised and anonymous incident report forms, centralised collation and analysis of incident reports and, to a limited extent, adverse event codes from the VIMD and VEMD databases. Strategies for preventing identified incidents will also be assessed.

The formal evaluation will also include recommendations for approaches to adverse incident monitoring and management which can be generalised across the hospital system.

7.6 Performance Indicator Development

The Acute Health Quality Committee has identified the development and refinement of indicators of health care quality as the priority initiative for the 1998 - 99 financial year. Further work will be undertaken to identify selected useful indicators for monitoring at State level in the following areas: clinical care; safety of care; effectiveness of care; and access to outpatient services. Initial priorities within these areas will be discharge planning; infection control; and adverse events. Existing hospital access indicators will also be reviewed and redeveloped.

It is intended to keep indicator reporting requirements to a minimum and to develop a set of key performance indicators that reflect quality monitoring currently occurring in the acute health sector. Networks and hospitals will be consulted at key stages of the indicator development program including the strategies for benchmarking, reporting and effectively using performance indicator data.

The Hospital Services Report, published quarterly, contains a wide range of data about the health care system, including private health insurance; hospital throughput; waiting lists; emergency department activity; ambulance bypass; and unplanned readmissions. The report is targetted to the general public and the hospital sector.

7.7 Patient Feedback Indicators

Patient perceptions and feedback on quality and performance of acute health care services are an integral part of quality improvement. Stage 3 of the Patient Satisfaction Survey was conducted in 1997 - 98. Patients from all Victorian public hospitals were interviewed and there was public release of comparative benchmark data for grouped hospitals.

The Department intends using the aggregate outcomes of the survey to focus future quality improvement initiatives. Further work is currently underway to determine useful patient feedback measures for specified care processes (access, discharge planning, complaints systems and quality of information); the best options for regular monitoring of these measures; and appropriate benchmarks and performance targets.

7.8 Accreditation

The current funding incentives to encourage hospitals to achieve accreditation will continue until the year 2000. By this time accreditation/certification will be mandatory for all acute hospitals funded by the Department. Hospitals may currently seek accreditation through the Australian Council on Healthcare Standards Evaluation and Quality Improvement Program (EQuIP) or certification through the ISO 9000 Quality Management System.

The Department will provide limited seeding funding to support networks and hospitals who wish to use concurrent approaches to quality assessment and improvement, including the Australian Quality Awards and Quality Committed Enterprise Programs offered through the Australian Quality Council. However, use of these programs alone will not currently satisfy Department accreditation/certification requirements.

Hospitals not currently accredited/certified, or booked for survey, by the ACHS or ISO assessors by June 30 1998, will be required to advise the Department of their intended plan to meet accreditation requirements by the year 2000.

The Department will require hospitals to provide evidence of their level of achievement following an organisation-wide accreditation or certification survey or assessment. The results should be forwarded to the Department within 30 days of results being notified by the accrediting or assessing body.

In the event that accreditation/certification is not awarded the reasons for this should also be advised. The Department response will be based upon the following principles:

• The hospital will be given the opportunity to address areas of non-conformance;
• If appropriate, the hospital will be referred to a professional body for assistance;
• If necessary there will be further investigation and/or third party review; and
• Community access to public health care services will be preserved.

7.9 Statutory Immunity

Currently all metropolitan network hospitals and 70 per cent of rural hospitals have been granted statutory immunity under Section 139 of the Health Services Act 1988. A range of other non-hospital agencies and medical colleges also have statutory immunity provisions for quality assurance processes.

The Public Health Division has let a tender for an evaluation of the effectiveness of the statutory immunity provisions and the scope for improvement with respect to non-hospital agencies. The results of this review will be available by July 1998. The outcomes of this evaluation will inform the review of statutory immunity provisions within the acute sector.

Hospitals without accreditation/certification by a third party and which have not been granted Statutory Immunity must send the Department a comprehensive quality improvement plan. Hospitals in this category will be asked to provide these plans by December 1998.