Quality presentation for HANOI

Governmental & Institutional responses UK National Health Service NHS 2001: Building a Safer NHS for Patients: Implementing an Organisation with a Memory  USA; Institute of Medicine IO

How should we think about it for our

Mental Health Services?

Victor Storm

Director of Mental Health, Sydney & South Western Sydney

Local Health DistrictsNational Institute of Mental Health, Bach Mai Hospital, Hanoi

October 2012

 I have no other conflicts of interest or disclosures

Talk Outline

 IDEAS have a half life of ideas; meso-facts & examples of change

 What were the major impacts on improved health outcomes?

 What impacted on mental health services?

 Principles that guide quality health care delivery

 What has driven quality focus?

 Methodologies & Tools for improving quality

 The challenges to research and innovation from marketing

Ideas have a half life - Arbesman

 Many medical schools tell their students that half of what they've been taught may be wrong within five years—the teachers just don't know which half.

 Facts change in a regular, predictable manner and obey mathematical rules: “Once we recognize this, we'll be ready to live in the rapidly

changing world around us.”

Samuel Arbesman “THE HALF-LIFE of FACTS” Penguin 2012

This is an idea which has

decayed over the past 50 years

And Transformed into this: Australian Plain Packaging of Cigarette Packets

Most of us need to be guided by basics

We should start with basic principles; this way you avoid

mistakes This is essential when scientific knowledge and

understanding is fluid & dynamic

The aspiration of healers over centuries has been to promote health & healing and to minimise harm Quality has been

implicit in the delivery of service.

What have been past major

QUALITY Initiatives for health?

 Access to clean water

 Mass Immunization

 Control of sepsis (particularly in child-birth)

 Literacy (particularly for women)

 Therapeutic advances (antibiotics etc) have had lesser impacts

 Major impacts on health now will be achieved by Smoking cessation, minimising alcohol consumption, dietary management and weight control and regular exercise

What about Mental Health care?

 Major impact was offering care in safe & secure environments;

development of asylums

 Most people who entered left within 3-6 months

 BUT over time an aggregation of people who had illness without

recovery led to overcrowded facilities, with poor quality care This

often gave rise to public scandal.

 Impact of ECT and Psycho-tropics medications had a major impact on those who remained in asylums for extended periods

What should health care be? 1

 SAFE : avoiding injuries to patients from the care that is intended to help them

 EFFECTIVE: Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit ( avoid underuse and overuse)

 PATIENT CENTRED: Providing care that is respectful and responsive

to patient preferences, needs and values and ensuring that patient values guide all clinical decisions

What should health care be? 2

 TIMELY: Reducing waits and sometimes harmful delays for those who receive care and those who give care

 EFFICIENT: Avoiding waste, including waste of equipment, supplies, ideas and energy

 EQUITABLE: Providing care that does not vary in quality because of personal characteristics, such as gender, ethnicity, geography,

location and socio-economic status.

Why has quality become a

focus within health services?

 Expanding health care costs without significant change in overall health outcomes, due to aging populations & health technologies

 Majority of health expenditure on an individual in Western Countries occur in the last 6 months of life

 Mis-application of care/Errors in treatment

Health care Spending as % of GDP 2008

Governmental & Institutional responses

 UK National Health Service NHS 2001: Building a Safer NHS for Patients: Implementing an Organisation with a Memory

 USA; Institute of Medicine IOM 2001

 Crossing the Quality Chasm; A New Health System for the 21 st

Century

 “Between the health care we have and the care we could have lies not just a gap, but a chasm”

Multiple Perspectives: macro to micro

International: (WHO, Human

Rights)

National: Welfare of Citizens;

Productive Citizens

Bureaucracy: Health Departments;

Police; Justice & courts

Institutional: Hospitals & Health

Communities: those who have

people who suffer

Families & friends: those who care

for those who suffer/recover

Individuals: those who suffer

Methodologies & Tools

 Multiple contributing solutions require commitment & time

 Lessons from Industry: Aviation & Motor Industry eg Quality Control @ Toyota & what happened when they went from 3 check to 2 check

industrial process

Generic Health Methods

 Public Health indicators

 Functional Health Status measures

 Report Cards

 Health service utilisation data

 Consumer & Carer satisfaction surveys

 Formal External Accreditation of Health Services

Specific Tools

 Continuous Quality Improvement (CQI), Total Quality

Management (TQM) or other variants

 Quality assurance procedures & practice

 Condition/disease specific outcome measures

 Service practice protocols (remember “facts” have an expiry date)

An approach to any quality initiative cycle

Health System Performance Domains 1

from Key Performance Indicators for Australian Mental Health Services

 Effective: Care, intervention or action achieves desired outcome (Sub domain-Metric: Consumer outcomes - change in consumer’s clinical outcomes; Carer

outcomes - TBD; Community tenure - 28 day

re-admission rate)

 Appropriate: The care, intervention or action provided

is relevant to the consumer’s and/or carer’s needs and based on established standards (Sub-domain-Metric: Compliance with standards - National Service

Standards; Relevance to consumer & carer needs -

TBD) TBD= To be Determined

Health System Performance Domains 2

from Key Performance Indicators for Australian Mental Health

Services

 Efficient: Achieving desired results with most cost

effective use of resources (Sub-domain - Metric: Inpatient care - Average Length of acute IP stay & cost per episode; Community care - Average treatment days & Average cost per 3 month community care period)

 Accessible: Ability of people to obtain health care at the right place and right time irrespective of income,

geography and cultural background (Sub-domain -Metric: Access for those in need - Population receiving care &

new client index; Local access -comparative area

resources; Emergency response - TBD)



Health System Performance Domains 3

from Key Performance Indicators for Australian Mental Health Services

 Continuous: Ability to provide uninterrupted,

coordinated care or service across programs,

practitioners, organisations and levels over time (Sub-domain - Metric: Continuity between

providers - TBD; Cross-setting continuity - admission & Post –discharge community care ; Continuity over time -TBD

Pre-Health System Performance Domains 4

from Key Performance Indicators for Australian Mental Health Services

 Responsive: Service provides respect for persons and

is consumer and carer orientated: respect for dignity, confidential, participate in choices, prompt, quality of amenities, access to social support networks, and

choice of provider (Sub-domain-Metric: Consumer & carer experience of care; Consumer & carer

participation-Consumer outcomes participation))

 Capable: An individual or service’s capacity to provide

a health service based on skills and knowledge

(Sub-domain - Metric: Provider of skill & knowledge

-TBD; Outcomes orientation-Outcomes readiness)

 Safe: Potential risks of an intervention or the

environment are identified and avoided or

minimised (Sub-domain - Metric: Consumer

safety-Rates of seclusion; Carer safety - TBD;

Provider safety - TBD; Community safety - TBD)

 Sustainable: System or organisation’s capacity to provide infrastructure such as workforce, facilities and equipment, and be innovative and respond to emerging needs (research, monitoring)

(Sub-domain – Metric: Workforce planning- TBD; Training investment -TBD; Research investment -TBD)

Health System Performance D omains 5

from Key Performance Indicators for Australian Mental Health Services

 Research & its application Often takes much longer than we would wish

 Essential we are driven by hard evidence (not just publication)

 Scepticism is healthy and we should ask for detail.

 How transparent is the information?

 Are conflicts declared and whose interests are served by the

application of innovation?

 How do we deal with skilled marketers?

The lessons learned from the skilled marketing/advertising of two legal

drugs

And when public health

experts get into marketing

Direct to Consumer (DTC) Marketing

Direct to consumer (DTC)

DTC Spending in USA 1996-2012

WHY DTC is done

An approach to any quality initiative

 Samuel Arbesman “The HALF-LIFE of FACTS” Penguin 2012

 UK National Health Service NHS 2001: Building a Safer NHS for

Patients: Implementing an Organisation with a Memory

 National Institute of Clinical Excellence (NICE) Clinical Guideline 136 2011:Service User experience in adult mental health: Improving the experience of care for people using NHS adult mental health services

References 2

 USA: Institute of Medicine (IOM) 2001: Crossing the Quality Chasm; A New Health System for the 21 st Century

 Australia NATIONAL MENTAL HEALTH PERFORMANCE

SUBCOMMITTEE 2011: Key Performance Indicators for Australian Public Mental Health Services SECOND EDITION

References : Websites 3

 Australian Council of Health Care Standards (ACHS)

http://www.achs.org.au

 The Joint Commission (USA) www.jointcommission.org

 The National Institute for Health & Clinical Excellence (UK)

http://www.nice.org.uk