Systems redesign for better cancer care

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Professor of Cancer Services, University of Sydney
Chairman, Australian Council for Safety and Quality in Health Care


Cancer care is a complex and important component of health care and safety and quality in cancer care is dependent on the approach that the whole health system takes to the issues of safety and quality of care. Setting benchmarks for quality performance in complex systems is difficult and may involve many different dimensions including appropriateness, effectiveness, efficiency, responsiveness, accessibility, safety, continuity, sustainability and capability. Of these dimensions, safety has been identified as the foremost dimension of quality and the most important to patients and their families1.

The Australian Council for Safety and Quality in Health Care (ACSQHC) was formed by all the Australian Health ministers in January 2000, with its role being to lead national efforts to promote systemic improvements in the safety and quality of health care in Australia with a particular focus on minimising the likelihood and effects of error. The Council’s first report to Health ministers in July 2000, Safety First2 identified a broad five year plan. The ministers agreed in principle to allocate $50 million for this work to improve safety. By doing this they identified safety as core business of the health system. After wide consultation with professionals and consumers, the Council’s “National Action Plan for 2001”3 was produced. The work detailed in this plan has a major emphasis on developing and strengthening national standards with educational support to enable these standards to be put in place across the system. All areas of the Council’s work will help those giving care to cancer patients. However, the focus in the next few months will be on key priority areas.

High risk aspects of the system will be addressed by the development of national standards with associated education and compliance support to reduce hospital-acquired infection, promote safer use of drugs and blood products and improve assessment of patients. Other key priorities include developing national standards for:

  • credentialing and performance assessment of all who have independent decision making responsibility; specialist vocational registers;
  • curricula for educational modules in systems safety, human factors and communication;
  • national audits and benchmarking;
  • full disclosure of adverse events and saying “sorry”; and
  • improved organisational accreditation, certification and licensing, addressing best practice, structured risk management, team work, team training, resource use, skill mix and safety standards.

The Council’s work will also address the better use of data to ensure that lessons are learnt. This will involve:

  • improved reporting and review of deaths in health care facilities;
  • analysis and dissemination of results of coronial investigations;
  • national standards for incident monitoring and assessment; and
  • improved methodology to allow reporting of quality improvement in the system.

There has already been a national consultative consumer workshop and seminar and the first Asia Pacific Forum will be held in Sydney in September 2001 to share international experiences in safety improvement.

We anticipate that the end product of the work of the Council will be that those working in health will be working in a culture of safety which will allow the system and its facilities and resources to be better managed as individuals feel secure and are rewarded for seeking, identifying and reporting errors and opportunities for improvement. The system will provide care informed by the needs of consumers and there will be national standards to be met in key areas with better and more appropriate data collection, analysis and feedback.

This work, focused on improving safety, will complement other national work by the National Breast Cancer Centre, the Australian Cancer Network, the National Health and Medical Research Council, National Cancer Control Initiative, Cancer Councils and the Royal Colleges to foster best practice using evidence-based care and the production of evidence-based guidelines. All of these groups also encourage organisational change for safe, high quality care by encouraging the provision of multidisciplinary care and evidence-based decision-making. Evidence-based medicine has been defined by Sackett and others as “the conscious and judicious use of current, best evidence from clinical care research in the management of individual patients”4 and therefore evidence-based decisions are those involving knowledge of the research evidence, clinical expectations and patient preference5.

The National Breast Cancer Centre is currently investigating models for multidisciplinary care that fit the Australian health care system. The Centre has defined the five principles of multidisciplinary breast cancer care that are equally applicable for other cancers:

  1. A team structure is necessary with a core team of health professionals that can be expanded as necessary to provide a full range of opinions and care.
  2. Provision of a full therapeutic range is necessary and this should be made possible by establishing collaborative links, not limited by geography or unit size.
  3. Standards of care must be identified and agreed to and these standards should be consistent with guidelines. Treatment plans must involve the patient and be informed by all possible information available at the time. This may involve collaborative links with other units and of course, all clinicians involved must be actively accessing a Continuing Provisional Developing Program.
  4. There must be a communication framework to ensure interactive participation of the full team and while this may be a face to face meeting, our population density, scattered resources and great distances mean other means of communication may be necessary.
  5. Involvement of the patient. Often the informal links that individual clinicians use for multidisciplinary consultation are not known to the patient. It is important that patients have appropriate information, supportive care and understanding of the input of the team.

There is no doubt that local or linked “virtual” multidisciplinary care teams require much better data recording analysis and feedback as well as other organisational change to establish links but with this extra support and following the principles of evidence-based decision making and multidisciplinary care we should be able to provide “best practice” care to all.

To look into the future, one would see clinicians credentialed according to both quality and competence, with performance agreements related to evidence-based medicine and multidisciplinary care in a structure with adequate data support and benchmarking so that they are contributing to national audits, registering patients on appropriate trials and with regular accurate feedback of their own performance in relation to agreed clinical pathways. They will have appropriate support for information exchange and patient education and will work in facilities accredited on the basis that this situation exists and that the organisation has an appropriate integrated risk management program, appropriate linkages to other facilities, appropriate skill mix of staff and actively encourages teamwork and team training.

While it is often not the case now, it will be expected that palliative care and rehabilitation experts will be part of the core cancer care team and that reporting the outcomes of care to the community will be usual practice. Modern information technology and data collection analysis and the virtual environment will be the technology that underpins these changes. The Australian Council for Safety and Quality in Health Care looks forward to working closely with all who provide health care to bring about systemic change to make care safer and of better quality. 

References

1. C A Vincent. “Risk, Safety and the dark side of quality.” British Medical Journal (1997): 1715-6.

2. Australian Council for Safety and Quality in Health Care. Safety First. Report to Australian Health Ministers Conference. Commonwealth Department of Health and Aged Care, Canberra, July 2000.

3. Australian Council for Safety and Quality in Health Care. National Action Plan 2001. Commonwealth Department of Health and Aged Care, Canberra, February 2001.

4. S L Sackett, W M C Rosenberg, J A Gray, R B Hughes, W S Richardson “Evidence-based medicine. What it is and what it isn’t.” British Medical Journal 312 (1996): 71-2.

5. R B Haynes, D L Sackett, J A Gray, D J Cook, G H Guyatt. “Transferring evidence from research into practice.” Evidence-Based Medicine 1: 196-197.

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