eMJA: Detecting and reducing hospital adverse events: outcomes of the Wimmera clinical risk management program

Letters

Detecting and reducing hospital adverse events: outcomes of the Wimmera clinical risk management program

Kathy M Brown, Humsha Naidoo and Arona E Offenberger

MJA 2002; 176 (4): 192-193

To the Editor: On reviewing the results of the Wimmera clinical risk management program,1 we are prompted to ask whether the model can be generalised to a tertiary hospital. The program outlined by Wolff and colleagues is a good model for local quality improvement and provides a foundation for developing a model for tertiary hospitals. However, in considering its applicability to tertiary hospitals, a number of issues must be addressed.

The number of separations and emergency department presentations at tertiary hospitals does not lend itself to review of all medical records. Such review is time- and resource-intensive and probably unrealistic in a tertiary setting. A sampling strategy might be more suitable, but would introduce the possibility of sampling error and missing adverse events.

The availability of medical staff to review records is also limited, with clinicians often having public, private and teaching commitments. It would also not be feasible for a medical director to be involved regularly in the day-to-day tasks of the process. Nevertheless, these issues could be addressed by allocating the review process to a dedicated, trained team. Development of a review pathway would ensure participation of senior medical or management staff when necessary.

The interface between tertiary hospitals and local general practitioners is broader and less defined than in rural areas, making the involvement of GPs difficult.

The clinical mix and complexity of patients requiring tertiary care differ significantly from those at a rural base hospital, and restricting screening criteria for adverse events to eight items, as in the Wimmera program, would likely result in adverse events being missed. In addition, the clinical structure of tertiary hospitals is not uniform, and specific criteria may need to be developed to address the clinical specialties of the hospital.

Lastly, in this era of cost containment in healthcare, Wolff et al did not address the cost of its clinical risk management program. While this is not a fault in the study, cost would be an essential consideration in generalising the program to a tertiary hospital.

The model used in the Wimmera program has limitations when considering adaptability to tertiary hospitals, because of issues of scale and day-to-day practicalities. Further examination of the costs involved in ongoing operation of the program and a cost–benefit analysis are required. In addition, investigation is needed into feasible options that deliver useful results in a tertiary setting before a quality improvement model can be developed that is relevant, appropriate and cost-effective for tertiary hospitals.

Wolff AM, Bourke J, Campbell IA, Leembruggen DW. Detecting and reducing hospital adverse events: outcomes of the Wimmera clinical risk management program. Med J Aust 2001; 174: 621-625. <eMJA full text> <PubMed>

(Received 5 Sep 2001, accepted 31 Oct 2001)

Intensive Care Unit, Frankston Hospital, Melbourne, VIC.

Kathy M Brown, Associate Charge Nurse.

Clinical Services, Austin and Repatriation Medical Centre, Melbourne, VIC.

Humsha Naidoo, Deputy Director.

Department of Human Services, Melbourne, VIC.

Arona E Offenberger, Fellow in Medical Management.

Correspondence: Dr Arona E Offenberger, Department of Human Services, 10/589 Collins Street, Melbourne, VIC 3001.arona.offenbergerATdhs.vic.gov.au

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In reply: Detecting and reducing hospital adverse events: outcomes of the Wimmera clinical risk management program

Alan M Wolff, Jo Bourke, lan A Campbell and David W Leembruggen

MJA 2002; 176 (4): 193

In reply: The model developed in the Wimmera hospital for clinical quality improvement has formed the basis for quality improvement systems in several regional and tertiary hospitals in Australia. The resources required to implement the model have been costed, and the Victorian Department of Human Services has allocated $4.8 million to establish clinical risk management programs based on the Wimmera model in every Victorian public hospital in 2001–2002.1

Whichever programs are implemented, some adverse events will be missed. However, not all medical records need to be reviewed, nor all adverse events found. Regular identification of some events provides significant opportunities to improve care.

As clinician time is limited, some hospitals that have implemented the Wimmera model have paid clinicians with existing appointments for extra hours to participate in risk-management programs. Although feedback to general practitioners is logistically more difficult in a tertiary centre, it can still provide valuable information if limited to only a sample of inpatients. We agree that some departments in tertiary hospitals, because of their specialised nature, would need to develop additional screening criteria.

The actual cost of running a clinical risk-management program based on the Wimmera model depends on how many components of the model are implemented, but in our experience should not exceed 0.5% of a hospital's total budget. Cost–benefit analyses are difficult to undertake, as some adverse events arise through underuse of available evidence, and additional resources would be needed for full implementation of the evidence (eg, giving prophylactic antibiotics immediately before surgery to prevent postoperative infection,2 or low molecular weight heparin postoperatively to prevent thromboembolism3).

We believe that in any institution, whatever its size, the initiation of effective programs for clinical quality improvement needs both enthusiastic support from the highest level of management and champions at the "coalface" of patient care. If these two elements are present, adequate resources will often be found. However, providing resources without appropriate clinical and administrative support is unlikely to improve patient care.