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Section A - Policy
7. Quality Systems & Care Monitoring
Development and implementation of health care quality indicators will continue in 1999-2000. During 1998-1999 substantial work was undertaken on development of selected indicators for monitoring at the state level including: clinical care; patient feedback and complaints; access to care; and safety and effectiveness of care. These are in addition to indicators relating to specific initiatives and strategies, for example, maternity services enhancement and effective discharge.
The Department has commissioned a major project to identify a concise set of clinical indicators with applicability at various levels across the acute sector. The Acute Health Clinical Indicators Steering Committee is overseeing this project and others relating to clinical indicators. Indicators will be progressively introduced over the 1999 - 2000 year. Issues relating to the implementation, use and reporting of clinical indicators are being considered by the Steering Committee and will be communicated to all stakeholders by December 1999.
Patient perceptions of, and feedback on, their hospital experiences are an integral component of quality improvement programs. The Department has monitored patient satisfaction since 1993. The most recent major statewide survey was conducted and reported during 1997 - 98. Data from this survey were used to derive and inform a process for developing indices of satisfaction in focused areas of patient care. Work has subsequently been commissioned to research and develop a model for ongoing monitoring of patient satisfaction/feedback that will enable valid indices of care in Victorian public hospitals to be regularly reported and benchmarked.
A system for regular monitoring and reporting of patient feedback will be progressively introduced during 2000, following consultation with networks and hospitals.
Accreditation will continue as a cornerstone of acute health quality policy. Following a review of current accreditation policy and on the advice of the Acute Health Quality Committee the approach has been modified and strengthened for 1999 - 2000.
Accreditation will be mandatory for all providers of acute health care services from 2000. Hospitals may seek accreditation through the Australian Council on Healthcare Standards Evaluation and Quality Improvement Program (EQuIP), ISO 9000 Quality Management System or other equivalent programs. An "equivalent program" must comply with specific criteria to be deemed suitable and hospitals electing to use such programs and wishing to receive funding must seek prior approval from the Department. The criteria are that:
- The program must be health care specific or be able to be adequately modified to meet the needs of the health care industry;
- The standards or criteria for assessment must be externally set by a nationally or internationally recognised body and regularly updated;
- The accreditation/certification process involves an external review process by independent and trained surveyors/assessors affiliated with a nationally or internationally recognised body; and
- Accreditation/certification is awarded for a defined period of time and includes internal and external mechanisms for ongoing review and improvement.
Grants have been provided to hospitals since 1993 to facilitate the achievement of accreditation. In place of grants, the Department will in 1999 - 2000 provide accreditation bonuses to support networks and hospitals in developing improved systems for data collection for the monitoring and reporting of performance indicators and for quality improvement projects addressing reported outcomes of accreditation/certification surveys.
Where a hospital has been delayed in presenting for, or achieving, accreditation, a comprehensive quality plan should be submitted to the Department for assessment by September 30 1999. These plans must provide detail of arrangements in place for external survey and accreditation.
In 1999 - 2000 hospitals will be required to provide information about the outcomes of accreditation/certification surveys. A new reporting framework for accreditation outcomes will be introduced in February 2000, after a period of consultation with networks, hospitals and other stakeholders. It is proposed that networks and hospitals provide to the Department a summary report within 60 days of receiving survey reports or following the outcomes of any appeals process. Reports should specify the level of accreditation achieved, expiry date, recommendations made and commendations noted for outstanding practice. Reports should also include information on how hospitals intend responding and acting upon the issues or recommendations raised by accreditation surveys.
The Department will report in the Hospital Services Report a list of accredited hospitals, the period of accreditation which has been awarded and the accrediting organisation. The public disclosure of more detailed survey information for the 2000-2001 year will be considered by the Department following further consultation.
7.3.2 Accreditation Indicators
Indicators at state and hospital level which reflect on accreditation outcomes will be developed in 1999 - 2000. The total number of high priority recommendations (safety and clinical issues) made will be monitored and reported in aggregate at the state level. Indicators that relate to the ratio of recommendations to commendations as defined by assessment rating scales will also be considered.
Section 139 of the Health Services Act 1988 provides statutory immunity for the activities and participants of prescribed quality assurance bodies to promote full and open discussion of quality issues, with the aim of enabling improvement of health care services. Applications for Statutory Immunity are granted following an assessment by the Department against the criteria established in the Act. A statutory immunity register is maintained by the Department and currently lists details for approximately 90 public and private hospitals that have been granted immunity for their quality assurance committees.
A review of Statutory Immunity provisions pertaining to the acute sector has been commissioned, to determine the degree to which the provisions are used; to evaluate their effectiveness in improving the quality of care; and to provide recommendations as to how the provisions may be best administered.
When the review report has been received information on recommendations and any proposed changes to arrangements for seeking statutory immunity will be provided to networks and hospitals.
Complaints about acute health services provide a basis to identify and improve the quality of care. The Health Services (Conciliation and Review) Act 1987, (The Act) requires that, where reasonable and appropriate, complaints received be resolved directly with the service provider in the first instance. Networks and hospitals must have accessible and effective complaints management systems in place.
In 1999 - 2000 the Department will pilot two indicators relating to the management of patient complaints. The first is an indicator of the effectiveness of complaints management, based upon those complaints which are resolved at the local level and those which are externally referred for investigation and conciliation.
The second indicator relates to the provision of data to the Office of the Health Services Commissioner (OHSC), an independent statutory authority established under the Act. The Commissioner’s role is to receive, investigate and resolve complaints from consumers and to provide support and assistance to providers in resolving complaints. Under s.33 of the Act, public hospitals, as prescribed providers are required to report to the Commissioner details of complaints received and action taken to resolve them. To offset some earlier difficulties in providing this information, the Department supported the OHSC in the development of the Health Complaints Information Project (HCIP), to assist hospitals record, manage and report complaints data to the Office. The HCIP pilot was completed in 1997 yet less than 30 per cent of Victorian public hospitals use the system and/or regularly report data to the Commissioner.
Hospitals are strongly encouraged to submit complaints data to the OHSC. It is not a requirement that HCIP be used for this purpose. However, data submitted would be expected to meet the requirements of the HSC minimum dataset. The proposed indicator will measure the number of hospitals reporting data to the OHSC.