Best practice in emergency care

Abstract

An entire edition of the Australian Health Review was recently devoted to Best Practice in the health care sector. The Editor Roy Green observes: “the ‘new competition’ is based on high-quality products and services which are designed and delivered to meet diverse and constantly changing customer requirements.” The managers of health services are being confronted with a whole range of new terms: Best Practice, Bench-marking, Workplace Reform and Enterprise Bargaining to add to the now almost historical Total Quality Management, Continuous Quality Improvement and Quality Assurance. Making sense of all this is the real challenge for health service management in the 1990s. The proponents of each new phrase or concept will sell it with a missionary zeal. They seem to have the innate ability to ensure that we mere mortals, charged with the responsibility of providing health services feel a real sense of inadequacy. We must be absolutely stupid not to be fully aware of the latest fashion. I am conscious of this feeling of ignorance when confronted with the other great mysteries of life - the Hare Clark electoral system, and how to operate a Fax machine. However, I have a feeling that the buzz words are only disguising a concept which is familiar and well trusted by health care professionals. Bench-marking describes the process of modelling your activities, both processes and outcomes, on other successful organisations. Best practice simply describes a comparison with the best available. In many respects, bench-marking is an admission that the evaluation of an organisation's performance is not necessarily straightforward. Were we in the business of making toothpicks, then ensuring quality would be relatively easy. Are they sharp? Do they break when inserted into the cheese? etc etc. Defining the quality of our product is much more difficult. Mortality, morbidity, satisfaction have all been used to try to determine if the quality of our services are consistent with best practice. How can we compare the treatment of heart attacks in Sydney with stonefish stings in Cairns? The complexity of our product and the lack of meaningful performance indicators makes such comparisons difficult. Historically, quality assurance in health services has been limited to ensuring the quality of inputs. Are practitioners trained appropriately? Are we using the best quality equipment available? More recently, supervision, audit and review, have broadened the quality assurance approach. At the individual patient level these combined approaches help to improve the quality of care. However, the organisational and management structures which enable individual practitioners to perform their tasks also need to be clearly defined and evaluated and the performance compared. Such measures focus on the providers view of what is required. What about the patient or customer? Are they satisfied with the service provided? Does our service meet their needs? Are our services properly addressing the needs of the community we serve? How many seriously ill patients are deterred from attending emergency departments by our failure to provide for their quality of service needs as well as quality of care? There is extensive literature on inappropriate attendance at emergency departments. Who defined ‘inappropriate attendance’? How are our services viewed by the patients and customers we serve? Do our services provide comfort and compassion as well as clinical accuracy? Are the patients' relatives looked after? Do we extend our services to meet the patients other needs such as medical retrieval and interhospital transfer? Perhaps we should ask our patients and clients what they think of our service? What bench-marking involves is the comparison of our performance with that of other organisations. Bench-marking should not be restricted to comparisons with other emergency departments. What can we learn by comparison with other providers of services or products? Do hairdressers talk about ‘inappropriate attendance’? “You don't need your haircut now. Go away!” What can we learn about emergency health services from pizza delivery or banks? Are we meeting the needs of clients who are not patients? Police request information and assistance. Communities seek help in disaster preparedness. Hospital administrators need to marshal their resources to meet their client needs. Bench-marking and best practice are concepts well suited to health care in general and emergency health care in particular. They are concepts which counter the simplistic cost cutting of the economic rationalists, with professional standards which recognise ‘best clinical practice’. The challenge for us is to ensure that all services we provide are appropriate to the needs of our patients and other clients of our services, and are consistent with the best practice available.