Quality in Australian hospitals--who cares?

Abstract

Hospitals' errors kill 14,000 a screamed Australian newspaper headlines in June 1995 [1]. The media were reacting to the release of the preliminary results of the Quality in Australian Health Care Study. This government-sponsored study was conducted over three years in a selection of Australian hospitals. It involved retrospective medical record review to identify adverse events, denned as unintended injuries or complications which arose from health care management and which contributed to the patient's hospitalization, to prolongation of the hospital stay, to discharge with a disability or to the patient's death. The study methods were based on those of the Harvard Medical Practice Study [2,3] carried out in New York in 1984, but the Australian study, conducted between 1992 and 1995, found a far higher prevalence of admissions associated with an adverse event (16.6%) than the percentage reported by the Harvard study (3.7%). It is difficult to tell whether this disparity reflects a real difference in the quality of health care in the two countries as there were methodological differences between the studies. For example, in the Australian study the definition of adverse event was based on potential preventability, not potential for litigation, further all admissions associated with an adverse event were included, regardless of when the adverse event occurred. Even when these are taken into account, however, the Australian adverse event rate remains more than double that of the Harvard Study. As might be expected, the possible explanations for the high percentage of adverse events noted in the Australian study were hotly debated. But methodology and results were not the only aspects of the study which generated controversy. The results were first reported not in an academic journal but in a statement made to the Australian Parliament by the Minister for Human Services and Health [4]. It was a further five months before any results from the study were published in a peer-reviewed journal [5]. In the interim there was a barrage of media reports which presented the results of the study in a sensational and alarming fashion. There was very little underlying analysis of the issues involved and the implications of the study for the Australian health care system. It is possible that the manner of release of the study results was intended, in part, to divert public attention from other politically pressing matters. If so, it succeeded admirably, at least in the short term. The Minister moved quickly to establish a Taskforce charged with reporting to all Australian Health Ministers, Commonwealth and State, on measures which should be adopted to reduce the incidence and impact of adverse events due to health care management in the Australian health system. One year later the report of that Taskforce has been quietly released [6]. In the meantime there have been changes of government at Commonwealth level and in several of the States. The processes initiated by previous governments cannot necessarily be expected to be enthusiastically embraced by incoming governments. Quality of health care is still high on the political agenda, but the report of the Taskforce has not been endorsed by ministers at this time. Out in the real world, most of the fundamental areas of concern flagged by the Taskforce are being addressed, although in a more low key way than that originally envisaged. These include improvement in implementation of clinical guidelines; interactive, computerized hospital information systems; accreditation and credentialling; performance indicators and consumer issues. The need to adopt a systematic approach to health care safety and quality and to involve closely those working in the system appears to have been taken on board, although the report's emphasis on accountability for quality of care by all those involved in health service planning and delivery, politicians, health care bureaucrats, managers and clinicians alike, has been downplayed.