Health services administration

Demand for medical education is increasing, and clinicians are struggling to maintain involvement in teaching and research activities. The settings of clinical training are changing and diversifying. The traditional model of medical education and the sustainability of academic medicine are under strain. Better support is required to ensure continued integration of research and education with clinical activities. Better coordination is required to overcome fragmentation within the medical education system, to ensure appropriate recognition for teaching and research across all clinical settings.

Catherine M Joyce BA(Hons), MPsych, PhD · Leon Piterman MB BS, MEdSt, FRACGP · Steven L Wesselingh BM BS, FRACP, PhD

General practice needs resolute and united medical leadership to ensure its fitness for survival Two-hundred years after the birth of Charles Darwin and 150 years after the publication of On the origin of species, we elected to pursue a Darwinian theme in the 2009 MJA annual General Practice issue. “Survival of the fittest” relates to the ability to adapt to the immediate environment, which, for medicine and health care, has certainly undergone some changes! Indeed, the Lancet recently redefined health as the ability to adapt.1 We wanted to explore just how medicine, and general practice in particular, has adapted to changing societal, commercial and political environments. There is no denying that societal changes, coupled with advances in science and technology, have brought substantive changes in health care. Not only are Australians now living longer than ever before,2 but we also enjoy a comprehensive health system that has made us “a nation free from financial worries that go with illness and incapacity”.3 But it must be acknowledged that there are smouldering tensions both within medicine and in its relationship with society — tensions that may well bring about fundamental change in medical practice. These catalysts for change have been comprehensively explored by Lilford and his colleagues from the Department of Public Health and Epidemiology at the University of Birmingham in an essay entitled “Medical practice: where next?”4 First, there is the rise of consumerism and corporatism. These days, medicine in the developed world is practised in societies consumed by consumerism, individual rights, and a low threshold for litigation. As a consequence, we now practise “defensive medicine”. The very word “patient” is decried by some and replaced by “consumers”, “customers” and “clients”, with their inherent service connotations. In fact, medicine has moved from an environment of individual professionals to one of corporate entities, as the financial lodestones of government subsidies and guaranteed cash flows attract corporate interests. Doctors practising in such environments are no longer considered valued partners, but are regarded simply as workers in a health care team involved in the production cycle. Second, administrators and accountants now reign supreme, with an emphasis on organisational performance. One of the unforeseen consequences of this corporatisation of general practice, with its production lines accommodating discrete and circumscribed tasks,5 has been the loss of continuity of care.4 The ever-present problem of patients’ access to health care has led to an increasing displacement of doctors by other health professionals.6 Nowhere is this more evident than in general practice. Doctors might still play a very important role in managing an illness, but they no longer exclusively direct the play. The roles of other primary health care providers and coordinators are evolving, and new tensions are being generated as they become involved in decision making, diagnostic procedures, prescribing and the organisation of referrals. Indeed, the widespread unhappiness and loss of morale among doctors, particularly general practitioners,7 is usually attributed to these and other pressures, especially when accompanied by diminishing autonomy and professional control. When practice frameworks, remuneration and regulations are determined by central bureaucratic commands, disempowerment and loss of professional control will result. Lilford and colleagues are particularly bleak in their predictions for the future, arguing that medicine may well lose its hegemony: What we are arguing is that the link between the work of a health professional and specific ‘professional background’ will become increasingly tenuous. This happened some twenty years ago in chemical pathology and more recently in public health, and the trend is now apparent in subjects as diverse as anaesthesia, primary care and ophthalmology. It is increasingly difficult to define ‘doctor’ in such a way as to distinguish the practitioner unambiguously from other clinicians in the healthcare team who have decision-making responsibility and/or who administer critical interventions.4 They go on to argue that intellectual and communication skills will become the most crucial competencies in health care, and that the consultation will reassert itself as the central encounter in health practice. This special General Practice issue of the Journal contains contributions that explore such diverse topics as the reform of health care policy and general practice (Kidd, Coote, Mara and Sturmberg et al), the development of models of care (Harris et al, Wakerman et al, Phillips et al and Hartigan et al) and medical education in general practice (Laurence and Black, Sen Gupta et al and Sturman et al). Together, they offer some insight into the future direction of general practice. Coote details the reforms in Australian general practice from 1989 to 2009 (Coote).8 He describes how successive governments enacted reform revolving around remuneration, regulation and accreditation, organisational frameworks, and governance. During this process, governments capitalised on the principle of “divide and rule”. This is not particularly difficult in Australia, given the multiplicity of representative bodies and players in general practice, including such diverse organisations as the Australian Medical Association, the Divisions of General Practice, the Rural Doctors Association of Australia and the academic bodies of general practice and rural and remote medicine. Moreover, the federal government is itself a major powerbroker in the reform process, in that a considerable proportion of general practice income is derived from Medicare, and the government effectively controls both the workforce and the scope and diversity of its practitioners.9 Of even more importance, perhaps, is the federal government’s capacity to create ongoing uncertainty with its endless cavalcade of inquiries and their potentialities for change. All of this reinforces the notion that reform of general practice should be fuelled by GPs and shepherded by resolute and united medical leadership. Australian general practice has had effective leadership in the past, but if it is to develop further changes in medical care, it will need a multi-representative overarching body. Sir John Tooke’s inquiry into the United Kingdom’s Modernising Medical Careers debacle made pertinent comments on leadership of the British medical profession that may also apply in Australia: Indeed the advice derived from individual medical professional constituencies frequently reflected the particular interests of that grouping rather than the interests of medicine and medical care as a whole ... At a national level the Inquiry acknowledges that the medical profession has frequently failed to proffer coherent advice on key issues of principle, reflecting in part a very complex organizational structure, which owes more to history than necessarily function or purpose. There has been a dearth of medical professional leadership over this period.10 Here in the Antipodes, things are essentially no different. Without such a structure and courageous leadership, the Darwinian evolution of general practice may well be driven by chance alone or, at the very least, a passive or submissive response to the environments imposed by successive governments, as recounted in this issue by Coote8 and Mara.11 If GPs caring for patients 50 years ago were to return today, they would be amazed by the profound changes that have occurred. Yet one constant remains: general practice will continue to be subjected to changing professional, political and social paradigms. In this environment, unless resolute and united leadership ensures its centrality in the process of reform, general practice will no longer be deemed “the fittest” and, according to the basic principles of Darwinian evolution, will not survive.

Martin B Van Der Weyden MD, FRACP, FRCPA

You can learn a lot about the future of Australian medicine by visiting the United States. Although I am home from my New York sabbatical, a short return trip allowed me to hear President Obama outline his plans for US health care reform to the American Medical Association. He noted that the American health care system is unfair, unaffordable and headed for bankruptcy. Paraphrasing loosely, it has features that are downright “un-American”. Strengths of the Australian system are the single payer (Medicare) for medical consultations and universal coverage. These will not happen in the US — Obama went out of his way to explain this. If they are not going to happen under Obama, it seems unlikely they will happen in the foreseeable future. The Obama plan does include what he calls the “public option”. This will make government-run health insurance — now available only to federal government employees — also available to the general population (or perhaps just the poor). Even this tentative move towards universal coverage has been heavily criticised by the Republican right as the first step on the pathway to the “evils” of socialised medicine. Unfortunately for the Obama plan, a significant number of Democratic senators don’t approve either. The worry is apparently that if the government starts supplying health insurance widely, it would compete with the private insurance industry. This would be un-American for many in the US, where the concept remains that the best health-funding system is a private one. The private system could be weakened by publicly funded insurance, as people moved from the private to the public not-for-profit sector. This assumes that the government insurance would be cheaper and would therefore entice people and employers away from private health insurance companies. In the end, the reasoning goes, the private system would collapse. Thus, the plethora of insurance plans will remain under the Obama plan and continue to bamboozle Americans. A new system making private insurance plans easier to compare is Obama’s weak solution to the current mess. Despite these negative features, there is much for us to learn from Obama’s eloquent speech and cleverly crafted US health care plan. He proposed to make it illegal for insurance companies to discriminate against people with pre-existing illness in obtaining medical insurance. This aligns with the Australian community rating-based system. He also proposed to reduce payments to hospitals with excessive early readmission rates. This would encourage hospitals to plan for patients’ mid- and long-term outcomes, rather than short-term state — something for Australia to think about. Obama pointed out that, in the US (and I suggest also in Australia), too much is spent on treatment that does not work. He particularly criticised incentives and other payments to doctors in the current US fee-for-service system, which he said encouraged doctors to do more tests and treatments than were medically needed. A collective cheer went up when he said that any health plan should allow doctors to be healers, rather than business people. However, the doctors in the audience went quiet when Obama, a lawyer, said he would not introduce a cap on malpractice claims, as he considered this would be unfair to patients. President Obama pointed out that there had been many unsuccessful attempts to modify the US health care system in the past. Whether or not the public insurance option is accepted, many elements of Obama’s plan will have direct relevance for Australia. He recommended that spending should increase on research to determine which medical care works best, pointing out that less than 50% of all cardiac care in the US is based on evidence. Large increases in funding for research on evidence-based clinical care and mechanisms for disseminating this information to doctors would have a substantial impact on American health care and would be (with perhaps some modification) directly relevant in Australia. In addition, the suggestion that mobile, accurate electronic records would be a goal of the plan may lead to technology that is directly applicable here. A major flaw in our health care system is the lack of ready access to accurate, verifiable medical data on sick patients. This is an even bigger problem in the more fragmented US system. If the problem is successfully addressed there with new technology, it could have major benefits for Australia. Although that part of the plan sounds good, it may contribute to the increasing potential for medical identity fraud, which I will discuss in my next postcard.

Jeffrey D Zajac MB BS, PhD, FRACP

The global financial crisis teaches us that systems like Medicare may have hidden long-term costs if they are based on short-term gains Dear Nic, Forgive my informality, but I have noticed that Australians like to shorten things — this even applies to Medicare. As a former TeRD (temporary resident doctor), I dreamed of being able to access Medicare for my own chronic diseases. Now I am a proud Australian citizen and grateful for the care my general practitioner gives me courtesy of Medicare. He could view me as a cash cow because my ailments make me eligible for more care plans than I’d like. Instead, he sees me and addresses my concerns when needed, and I have never felt processed or tick-boxed. Likewise, I want to give my patients quality, evidence-based and compassionate care. I love my job. I am at my best when trying to sort out what needs to be worried about and what does not. But although the Medicare system seems to be working for me as a patient, it does not work for me as a doctor. Medicare does not reward doctors who remain working in the “swampy lowland [of] messy, confusing problems [that] defy technical solution”.1 Generalists like me can ensure appropriate investigation and referral, and thus reduce costs of health care.2 GPs provide accessible and comprehensive care for common problems and provide continuity and team coordination for complex care.3 But we seem to have created an inverse care law in Australia, where specialists and GP subspecialists gain more income, and managing undifferentiated illness — often the hardest to sort out — is not rewarded. We pay premiums to people who cut out the known, not to those who draw out the unknown. To maximise this lower generalist income I am entitled to as a GP, I should conduct many consultations that last just over 5 minutes. However, taking a longer history and performing a focused physical examination (neither possible within 6 minutes) significantly increase my chances of weighing the multitude of factors that might contribute to a diagnosis or problem identification without recourse to expensive investigations (Box 1). Also, I am reminded that giving insufficient time or care to establishing a sound doctor–patient relationship and rushing consultations are two of the 10 “deadly sins” that will increase my risk of litigation.5 But this safer and, in the long term, cheaper care for my patients and my country generates less income for me in the short term. General practice grew up when most illness was acute and there were limited therapeutic options; the funding arrangements reflected the style of practice. Now, these arrangements put us in a quandary — the way to make the most money is to see people for a short time and deal with only one problem at a time. Telling people to come back for another visit seems grossly inefficient to me but is, admittedly, one way of earning a crust. Many patients want to save my and their time and bring in a list, little knowing that this will cost me income. I’ll use the example cited by the Professional Services Review (PSR), in which the clinical problems are more easily defined (a rare treat in my practice), to illustrate my less well defined billing problem. The PSR’s advice that a patient seen for a repeat script for a stable condition, an ear syringe and a blood pressure measurement would not qualify as a level C consultation even if the consultation lasted more than 20 minutes6 means that a level C consultation cannot be billed.6 However, the evidence shows that to do all three tasks well and safely is neither quick nor uncomplicated. Issuing a repeat script for a stable condition requires a check of the condition and its current impact on function, the medication, its known side effects, and potential interactions with other medications.7 The consultation should include questions about over-the-counter medications and complementary and alternative medicines (CAMs) taken, given that CAMs were reported to be used by 52.2% of 3015 people surveyed in South Australia, of whom 49.7% used conventional medicines on the same day and 57.2% did not report the use of CAMs to their doctor.8 According to medicolegal advice, before removing ear wax GPs should take a full history, asking specifically about ear discharge, previous perforation of the eardrum or ear infection carefully examine the external auditory canal recommend the use of wax softening agents explain the potential complications of the procedure ensure the person performing the ear syringing is fully trained ensure the equipment is correctly assembled. If the nozzle of the syringe is not properly secured, it may become detached and cause damage to the external auditory canal and/or tympanic membrane.9 The Heart Foundation’s Guide to management of hypertension 2008 recommends that doctors should “Manage identified lifestyle risk factors in all patients, whether or not BP [blood pressure] is elevated”.10 This cardiovascular risk assessment includes: personal and family history, smoking assessment, risk of diabetes, body mass index calculation, waist circumference measurement, exercise assessment, lipid assessment, and nutrition.10 Time and skills in motivational interviewing are needed to encourage change to reduce the risks identified.11 Once these simple, uncomplicated6 tasks are done, the GP should make clear, comprehensive and contemporaneous notes12 at a standard that enables another practitioner to take over care. Notes should include demographic and contact details, known allergies and a summary. Once the patient leaves, I begin my unpaid administrative work — reading letters from hospitals and emails from my Division of General Practice and practice manager; checking results; responding to patients’ queries; checking recall lists; and planning follow-up. Do you see my dilemma? Each task can be done quickly, yes, but only with potential longer-term safety risks and costs. If I do one thing per consultation, it would take three visits to deal with the problems. This has a higher overall cost in terms of making appointments for both patients and staff, patient time out of work and in travel — and what of the environmental costs of all this travel (unless I have persuaded them to cycle to the practice, thanks to my motivational interview about cardiovascular risk)? I would argue it is reasonable and good practice to do all this in one half-hour appointment and claim a Medicare Benefits Schedule item 36 long consultation. Medicare policy does not! Tell me, why not? Medicare and those practising medicine must learn the hard-hitting lesson from the current global financial crisis — that systems based on short-term gains have hidden long-term costs.13 You say you want GPs to provide quality care and include health promotion.14 Yet the announcement of increased audits of GPs’ billing practices coincides with a reduction in longer consultations of nearly a million from 5.53 million to 4.55 million between corresponding 6-month intervals in 2007–2008 and 2008–2009.15 I ask you, which do you want — short-term lower costs or longer-term better health for the people of Australia? Please value the role of the generalist; reconsider advice that “implementation of a 7 tier item structure in place of the current 4 tier item structure would improve the quality of health care in Australia” (Box 2);16 and use holistic cost–benefit analysis to inform health policy.13 Thanks for listening. Oh, and can I ask one final question? When you next need milk, will you implement the same system we apply to Medicare and just get the milk, and nothing else, on that visit to the shops? Or will you be reckless and go in with a list — wanting multiple things? Doesn’t it make much more sense to buy everything you need at once? Yours sincerely, Susan PS: please refrain from calling me Sue — I hate to be cut short. 1 A teenage girl presents to a general practitioner with recurrent headaches Option 1: brief history, referral for a computed tomography (CT) scan Time taken by GP: 6-minute consultation, 2 minutes to read report as normal, 6-minute review consultation. Income for the GP: two level-B consultations. Holistic cost–benefit analysis: cost of CT scan, radioactivity exposure for teenager, time off school and work for teenager and parent, anxiety about result, transport to and from x-ray department, return visit to the GP for brief review, but no engagement of teenager with GP to discuss emotional wellbeing, preventive or sexual health. Teenager has no understanding of tension headache. High chance of further consultations with other practitioners to establish cause for headaches. Option 2: comprehensive history and examination, no referral for CT scan Time taken by GP: 19-minute consultation giving teenager space to talk about home, education and employment, activities, drugs, depression, sexuality or suicide (HEADSS assessment tool).4 GP conducts a brief examination, then negotiates the management of tension headaches relating to upcoming school examinations and a boyfriend who will finish with her unless she agrees to start a sexual relationship. Nineteen-minute review consultation and discussion about contraception. Income for the GP: two level-B consultations. Holistic cost–benefit analysis: no expensive investigations, no exposure to radioactivity and no time off school or work or transport to attend x-ray department. Teenager understands nature of tension headaches and is able to take simple analgesics when needed. Teenager relieved to have talked about concerns and comfortable to access contraception when she is ready. 2 The Attendance Item Restructure Working Group seven-tier rebate system* The seven-tier rebate system creates a more consistent rebate per minute. At 2003 rates, this ranged from $2.00 to $2.50, whereas for the current structure, the rebate per minute ranges from $2.00 to $4.00 for consultations less than 10 minutes, but only $1.00 to $2.00 for consultations greater than 10 minutes. The proposed structure removes incentives towards consultations of just over 5 minutes. * Figure adapted from the Final report of the Attendance Item Restructure Working Group.16

Susan M Wearne MMedSc, FRACGP, FACRRM

To the Editor: The growing burden of chronic disease, an ageing population and recurring workforce pressures have been identified as three key challenges facing Australia’s health care system.1 Coping with these challenges involves developing strategies to ensure equity in access2 to health services, better preventive health measures and a more patient-centred health service — all with a focus on better health outcomes for Australians. In its discussion paper informing the development of the National Primary Health Care Strategy, the Australian Government sees general practitioner Super Clinics taking “an integrated and co-ordinated approach to delivering sustainable and efficient multidisciplinary models of care”,1 including chronic disease management in areas of high need. While laudable, this approach fails to acknowledge many of the outstanding services already available through existing community-based practices. Over the past decade, the Australian primary care landscape has seen the evolution of various forms of primary health care centres (de facto Super Clinics) — some owned and managed by practising GPs, others by corporate structures. By and large, these primary health care centres are focused on catering to the needs of local patients in the communities in which they are located. These smaller practices, often employing 5–10 GPs, provide the critical mass of Australian primary health care services.3 Many provide a broad spectrum of care —physiotherapists, podiatrists, practice nurses, occupational therapists, clinical psychologists, dietitians, counsellors, psychiatrists — that meets local community demands. This is the type of community care that deserves to receive equal priority from the Australian Government in further developing and improving local health services. The prospects for such a team-building model being successful are far more likely if the demand is “bottom-up”, with community support4 for the primary care team, rather than the government imposing a more rigid, pyramidal “top-down” model. Another approach might be for the government to provide some public services in already established primary care sector infrastructure. The possibility of taking fixed leases in established practices, as opposed to constructing large, expensive Super Clinics, would seem an obvious path and certainly merits consideration and evaluation of the benefits. Allied health professionals, practice nurses and aged-care support services could be employed to support existing on-site medical services.5 An integrated public–private sector model such as this has been used in Ireland6 and would fit well within the current Australian health structure and help consolidate the ongoing viability of many local practices. Such an approach would broaden the availability of allied health and specialist health services to many local communities, with new Super Clinics reserved for areas of genuine “high need”.1 It would also serve to send a strong message of support to primary health care professionals and their patients. The opportunity to invest in primary care infrastructure and shift emphasis onto primary care prevention deserves greater consideration.7 Local practices have largely proved their flexibility to adapt to local needs — the government should match their efforts with innovative programs that support local primary health care centres and help guarantee equity in access and services for all consumers.2

Thomas D Brett

In 2008, the Australian Primary Health Care Research Institute (APHCRI) held a Primary Health Care Workforce Roundtable with practising clinicians, policymakers and researchers, which drew on Australian evidence in health care policy, systematic reviews, and expertise and experience of participants. Key recommendations for an adequate, sustainable and effective primary health care workforce that arose from the meeting included: simplifying the Medicare Benefits Schedule, which is unnecessarily complex and inflexible; effectively funding undergraduate and prevocational medical and nursing education and training in primary health care; developing career structure and training pathways for general practitioners and primary health care nurses; developing of functional primary health care teams; and using a blended funding model, comprising fee-for-service as well as capitation for patients with chronic or complex needs. A report from the meeting, detailing these policy options, was submitted to the National Health and Hospitals Reform Commission for inclusion in their deliberations.

Kirsty A Douglas MB BS, MD, FRACGP · Frith K Rayner BA, PostGradDipJ · Laurann E Yen BSc, MPsych · Robert W Wells BA · Nicholas J Glasgow MBChB, MD, FRACGP · John S Humphreys BA(Hons), DipEd, PhD

Objective: To describe the factors and processes that facilitate or inhibit implementation, sustainability and generalisation of effective models of primary health care (PHC) service delivery in rural and remote Australia.Design: Case-study approach, including review of relevant literature, interviews with key informants, site visits and direct observation. Thematic analysis and template analysis were used with interview transcripts. An expert reference group provided feedback and advice on policy relevance.Setting and participants: Six PHC services in small communities across rural and remote Australia were selected based on results of a previous systematic review; they reflected diverse rural and remote settings and PHC models, and the multidisciplinary nature of PHC. Sites were visited, and 55 individuals associated with the establishment and operation of these services were interviewed between July 2006 and December 2007.Results: Independent and template analysis confirmed the usefulness of a conceptual framework, which identified three key “environmental enablers” — supportive policy; federal and state/territory relations; and community readiness — and five essential service requirements — governance, management and leadership; funding; linkages; infrastructure; and workforce supply. Systematically addressing each of these factors improves effectiveness and lessens the threat to service sustainability.Conclusions: Evidence from existing effective rural and remote PHC services can inform the health care reform agenda, in Australia and other countries. The evidence highlights the need for improved governance, management and community involvement, as well as strong, visionary political leadership to achieve a more responsive and better coordinated health system which could help eliminate existing health status differentials between cities and rural areas. In Australia, establishment of a single national health system, operationalised at a regional level, would obviate much of the current inefficiency and poor coordination.

John Wakerman MTH, FAFPHM, FACRRM · John S Humphreys BA, DipEd, PhD · Robert Wells BA · Pim Kuipers BA(Hons), MHumServ, PhD · Judith A Jones BA(Hons), GradDipAppSc(Comp), MSPD · Philip Entwistle PhD · Leigh Kinsman BHSc, MHSc

Major developments in medical education in Australia include increasing the numbers of students and educating more students within the community and in regional, rural and remote settings. Rapid growth of student numbers and the rural orientation of the James Cook University medical school course has meant that northern Queensland had to deal with these issues earlier than other regions. One solution has been to transform some rural hospitals into teaching health services. Two hospitals that have successfully made this transformation, and another on its way, suggest that important factors include local commitment to quality clinical services, medical and academic leadership, coordination of local resources, community support, and strategic links between key organisations. Transformation to a teaching health service involves senior doctors functioning as true consultants with cascading supervision as in the traditional consultant–registrar–resident model. As both clinical and teaching capacity develops, the workforce may stabilise, infrastructure and teaching culture are established, and long-term recruitment and retention strategies emerge. Applying these models in other rural and community settings may make it possible to manage the increased training capacity and address workforce needs without compromising the educational experience — indeed, it may be enhanced.

Tarun K Sen Gupta FRACGP, FACRRM, PhD · Richard B Murray FRACGP, MPHTM, FACRRM · Neil S Beaton MRCGP, DA, FACRRM · David J Farlow FACRRM · Clare B Jukka FACRRM, GCET · Natasha L Coventry BSc, DRANZCOG, FRACGP

The Australian Commission on Safety and Quality in Health Care is providing doctors with an opportunity to say what they think about safety and quality Early in 2009, the Australian Commission on Safety and Quality in Health Care (ACSQHC) developed a draft national safety and quality framework that sets out a vision for a health system that delivers safe and high-quality care (Box). At the ACSQHC, we now want to talk to Australians about how the safety and quality of the nation’s health care system can be improved. We are keen to hear from patients, consumers, clinicians, health service managers, policymakers and researchers about what aspects of safety and quality are important to them, the barriers they perceive to providing optimal care and suggestions for improving safety and quality. We have produced a detailed discussion paper as a starting point,1 and we need to know what you, the people on the ground, think about the ideas it contains. Opportunities for providing input include completing a short survey available on our website,1 providing written submissions and participating in meetings and focus groups. The result of these conversations will be a report, to be released mid 2010, that will include strategies for achieving sustainable, safe and high-quality patient care in all settings. The Journal has recently published articles by leading commentators and academics advocating health care reforms,3-7 and we have taken note of their views. A common theme was the need for a sustained focus on implementation — turning words into action — not just creating new policy. We know that safe and high-quality care requires the vigilance and cooperation of a wide range of health care staff, and that the success of initiatives to improve safety and quality requires the participation of doctors.8-11 Thus we believe it is crucial that frontline medical staff be involved in developing health policy in this area. Your participation in the conversations about safety and quality is essential to ensure that our final report is both practical and powerful. We know that it can be difficult for doctors to find time to participate in activities such as this one. However, we need to know about what you are doing to keep your patients safe, what gets in the way of this, and what changes you think are needed. We look forward to talking with you over the coming months and working with you to build a future of safe and high-quality patient care in Australia. Drop in to our website1 to read the discussion paper or fill in the survey to give us your views. Draft national framework for a health system that delivers safe and high-quality care1 Characteristics of safe, high-quality health care What it means for me as a patient or consumer Strategies for action by administrators, policymakers and providers 1. Patient-focused This means providing care that is respectful of and responsive to individual preferences, needs and values. It means a partnership between consumers, family, carers and their health care providers. Processes of care are designed to optimise the patient experience. I can access high-quality care when I need it. Develop service models which improve access to health care for patients. I can obtain and understand health information so that I can make decisions about my own care and participate in ensuring my safety. Increase health literacy. Involve patients so that they can make decisions about their care and plan their lives. Provide care that is culturally safe.* My health care is coordinated because people and systems work in partnership with me. Enhance continuity of care. Minimise risks at handover. Provide case management for complex care. Facilitate patient-centred service models. I know my health care rights.2 Promote health care rights. If I am harmed during health care, it is dealt with fairly. I will get an apology and a full explanation of what happened. Inform and support patients who are harmed during health care. 2. Driven by information This means enhancing knowledge and evidence about safety and quality. Safety and quality data are collected, analysed and fed back for improvement. Action is taken to reduce unjustified variation in standards of care and to improve patients’ experiences and clinical outcomes. My care is based on the best knowledge and evidence. Reduce unjustified variation in standards of care. Collect and use data to improve safety and quality. My clinical outcomes and experiences are used to build the evidence base for care and for strategies designed to improve care. Learn from patients’ and carers’ experiences. Encourage and apply research that will improve safety and quality. Continually monitor the effects of health care interventions. 3. Organised for safety This means that safety is a high priority in the design of health care. Organisational structures, work processes and funding models recognise and reward those who take responsibility for safety. I know that governments, health care managers and health care staff take responsibility for my safety. Clinicians, managers and governments recognise their responsibilities for safety. Our money funds a safe and efficient health system. Restructure funding models to support safe, appropriate care. Support and implement e-health. Design facilities, equipment and work processes for safety. I know that, when something goes wrong, actions are taken to prevent it happening to someone else. Take action to prevent or minimise harm resulting from health care errors. * Clinicians provide care that is culturally safe by recognising and respecting the cultural differences of the patient or consumer. Cultural safety goes beyond cultural appropriateness by creating better partnerships with people of different backgrounds.

Christopher J Baggoley FACEM, BM BS · Imogen E Curtis BComm(Hons) · Nicola J Dunbar BSc(Hons), PhD, MPS · Christine M Jorm MB, PhD, FANZCA

Acute medical units can help fast-track medical patient assessment and admission to hospital Hospitals in Australia are experiencing increasing numbers of medical presentations (ie, patients requiring admission under the care of a physician rather than a surgeon) in a context of ongoing restriction of inpatient beds. The resulting pressure on emergency departments (EDs) causes frustration for health care workers and administrators alike, as they struggle to meet key performance indicators that are designed to minimise the time that patients spend on trolleys in the corridors of EDs. Many hospitals have responded to this challenge by developing acute medical units (AMUs) that are equipped to fast-track patients with medical problems to the care of inpatient physicians (ie, staff physicians and visiting medical officers) and multidisciplinary teams who can best plan the management, care and disposition (destination after leaving the AMU) of these patients. On 24 April 2009, a seminar titled “Acute medical assessment units: improving care and flow for medical patients” was held at the Royal Children’s Hospital, Melbourne. The meeting was called by The Alfred Hospital, Melbourne, to assess the current state of evolution and performance of AMUs in Australia and New Zealand, and was supported by the Victorian Government Department of Human Services (DHS), Monash University National Health and Medical Research Council (NHMRC) Centre of Research Excellence in Patient Safety (CRE-PS) and the Internal Medicine Society of Australia and New Zealand (IMSANZ). Speakers from Australia and NZ addressed 210 attendees, including 78 doctors, 45 nurses, 17 DHS staff, 14 business analysts, 18 allied health professionals and pharmacists, 20 research educators and 10 representatives of relevant medical colleges. Here, we present the major themes presented for discussion and debate; speaker slides are available at http://www.crepatientsafety.org.au/seminars/. In the keynote presentation, Associate Professor John Henley (Visiting Professor, The Alfred Hospital) drew on years of experience running the AMU at Auckland City Hospital, NZ, and consulting on AMUs throughout Australasia. He emphasised the value of AMU staff working closely with ED staff, collocating the AMU and ED, and sharing administration across both units. At Auckland City Hospital, the AMU provides infrastructure, administration, and nursing and allied health support, but patients are seen by inpatient physician teams, with no default service provided in the AMU. This arrangement places the onus on the inpatient physician teams to attend to their patients promptly, and encourages continuity of care. This continuity is more difficult to achieve in AMUs that have their own medical staff, as distinct from inpatient physician teams. Henley also emphasised the importance of monitored beds, imaging equipment that is in close proximity to the AMU, and consulting rooms that permit urgent review of patients who are likely to require admission at the request of local general practitioners (thus bypassing the need for their assessment in the ED). In 2006, Henley co-authored a position statement on AMUs on behalf of IMSANZ.1 An international and historical perspective on AMUs was provided by one of us (P F J), drawing on extensive involvement in the establishment of AMUs in the United Kingdom. When the UK National Health Service applied severe penalties for hospitals that failed to move most patients from the ED within 4 hours, AMUs were developed throughout the country, supported by a new subspecialty — acute medicine. Introduction of a 4-hour rule is now pending in Western Australia, further focusing attention on AMUs. The importance of designing units according to the functionality required by individual hospitals was also emphasised — some units are designed to manage only patients with acute medical emergencies; some are designed to manage all medical admissions other than intensive care and critical care unit admissions; and some are primarily aimed at managing hospital bed issues, without a particular medical focus. Some units also accept surgical patients. This point was later reinforced by Associate Professor David Russell (Director, General Medicine, Royal Melbourne Hospital), who noted that the AMU should be regarded as a “philosophy of care”, not simply as a geographical entity. The value of effective change-management strategies in successful introduction of the AMU, particularly from the nursing perspective, was illustrated by one of us (L T O). Ms Glynis Jenkins (Project Coordinator, Acute Assessment Unit, Royal Perth Hospital, Perth) highlighted the importance of effective engagement with allied health staff, who play a crucial role in the AMU in both the UK and WA. Access block that results from delayed discharge and poor “back-door” availability of subacute and community care (paucity of options for discharging current inpatients who no longer require acute care but are not well enough to go directly home) is a major barrier to patient care, patient flow and ED key performance indicators. Dr Pieter De Villiers Smit (Acting Director, Emergency Department, The Alfred Hospital) described examples of how access block can impede patient management and safety. Professor Peter Cameron (Physician, Emergency Department, The Alfred Hospital, and Director, NHMRC CRE-PS), who chaired the session on identifying and addressing barriers, recently expanded on this topic in this Journal.2 Access block increases patient length of stay and incidence of adverse events, and decreases quality of care. In Australia, the excess mortality in hospitals attributable to access block matches that of the national road toll. Access block is a hospital-wide responsibility, rather than a problem within and for the ED itself, but is rarely acknowledged as such. Lugubrious specialty referral processes (whereby a patient can be referred, in turn, to several different subspecialties before being accepted for management) and significant delays in allocation of hospital beds contribute to access block. Associate Professor Ian Scott (General Physician and Director, Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane) reviewed the limited evidence base for efficacy of AMUs. In uncontrolled and often poor-quality studies, AMUs reduced estimated bed costs, and probably contributed to decreases in mortality, patient length of stay in hospital, ED admission waiting times and numbers of outlier patients (ie, patients whose allocated hospital bed is in a ward other than the ward that is usually managed by their admitting team). AMUs can also increase the allocation of patients to appropriate subspecialties, increase staff and patient satisfaction, and facilitate the direct discharge of patients from hospital without an increase in the readmission rate. Professor Don Campbell (Head, General Medicine Department, Clayton Campus, Monash Medical Centre, Melbourne) illustrated how simulation modelling and clinical audit data can be used to optimise the use of resources in AMUs. In the UK, acute medicine is practised as an independent subspecialty that has its own Society of Acute Medicine, whereas in Australia and NZ it is part of the training of a general physician. An ageing general physician workforce with a paucity of young trainees and consultants threatens the development of AMUs in Australia. One of us (H H N) presented alarming data from the 11th annual report of the Medical Training and Review Panel (MTRP),3 the Medical Labour Force Survey4 and the Specialist Advisory Committee in General Medicine of the Royal Australasian College of Physicians (RACP) (Surinder Ahluwalia, Education Officer, Education Deanery, RACP, personal communication). In 2006, general medicine was the third most populated physician specialty in Australia, after cardiology and gastroenterology, but had the highest proportion of ageing physicians and the smallest number of new graduates — only four general physicians received their RACP Fellowship in 2006, in contrast with 42 cardiologists and 19 gastroenterologists. At least 200 additional general physicians are required in Australia, although a structured workforce analysis in this area has not been undertaken recently. The numbers of trainees entering cardiology and gastroenterology exceeded the MTRP recommendations, but no recommendation is provided for general medicine. There appears to be little regulation of trainee numbers in each subspecialty by the RACP or health departments, and a relative oversupply of cardiology and gastroenterology trainees. Numbers of general medicine trainees in 2009 are higher than for 2007, but fewer than 40% of those who do some advanced training in general medicine actually practise in this specialty. A major workforce strategy to replenish the ranks of general physicians is required. Cross-training of subspecialty trainees (who are encouraged to maintain their general medicine skills) could provide an interim solution until numbers of dedicated general medicine trainees and dual specialty trainees increase. Additional appointments of full-time general physicians and affirmative action in remuneration could also help — this has been successful in the training of geriatricians. The meeting concluded with Professor Paddy Phillips (Chief Medical Officer, South Australia) summarising what administrators want from those designing and running their AMUs. He focused on four themes: clarity, reliability, accountability and working together, a useful checklist for any initiative. This was a timely presentation, as it was part of the session on implementation that was chaired by Ms Margaret Grigg, Assistant Director of the Access and Metropolitan Performance Branch within the Victorian Government DHS. This department will no doubt receive requests for additional funding of Victoria’s AMUs from the inspired attendees of the seminar.

Harvey H Newnham MB BS, FRACP, PhD · Campbell H Thompson DPhil, FRACP, MD · Paul F Jenkins MB BChir, FRCP, FRACP · Lauri T O’Brien RN, RM, BN

The future of academic medicine in Australia has been identified as a significant issue, but received little mention in the interim report of the National Health and Hospitals Reform Commission. Australia is at particular risk of failing to capitalise on what is happening globally with academic medicine. New “partnerships” between health services, universities and health research institutes should be encouraged for stimulating research and learning across the health sector. Such partnerships can drive translational research, provide full costing of research, and establish national and international networks of researchers and research funding. There are many interactions between Australian state and federal jurisdictions and their hospitals and primary care organisations, but these are often loosely coordinated and with little understanding of how universities and research institutes can help to deliver better and more efficient health care. Academic health science centres, as recently designated by the National Health Service in the United Kingdom, provide a useful model for consideration in Australia.

Peter M Brooks MD, FRACP, FAFRM

The current escalation in costs of Australia’s health care system does not appear to be sustainable. Sustainable financing requires direct engagement of consumers — instead of the current political process driven by special interest groups, targeted at gaining a larger share of the federal and state governments’ budgets. Reforms in the Netherlands, directed at achieving universal insurance with consumer choice of health fund, provide valuable lessons for Australia on how to design sustainable financing.

Johannes U Stoelwinder MD, FRACMA, FACHSE · Francesco Paolucci BEcon, MSc, PhD

Objectives: To determine whether redesign of pathology processes, including indicators of sample priority, could reduce patient length of stay (LOS) in an emergency department (ED), and assess the long-term impact of two indicators of sample priority on pathology clinical performance indicators for ED samples.Design, setting and participants: Two observational studies of de-identified data from standard databases were conducted — a single-site pilot trial of patients attending the ED of one hospital compared with historical controls, and a multisite study of 132 521 full blood count (FBC) requests for patients attending seven EDs that utilised either of two pathology process changes (coloured specimen transport bags alone, or coloured specimen bags plus blood tubes with a priority indicator).Main outcome measures: LOS in the ED was measured for the pilot trial, and collected-to-validated times for FBCs that fulfilled computer algorithm validation rules were measured for the multisite study.Results: In the pilot trial, the redesigned pathology process resulted in a 29-minute reduction (15.6%) in the median ED LOS for all patients (P < 0.001) compared with historical controls. In the multisite study, use of coloured specimen bags plus blood tubes with a priority indicator resulted in an 8-minute reduction (20.1%) in mean collected-to-validated times for FBC requests compared with FBC requests that used coloured specimen bags alone (P < 0.001).Conclusions: Our pilot trial revealed a direct relationship between pathology process design and LOS in the ED, suggesting that redesigned pathology processes can significantly reduce LOS in the ED. Our multisite study showed that collecting samples directly into blood tubes with an incorporated priority indicator reduces pathology test turnaround times. These data suggest that LOS in the ED can be significantly reduced by simple changes to pathology processes, such as collecting samples directly into specimen containers with an incorporated priority indicator.

Andrew J Francis MB BS(Hons), FRCPA · Michael J Ray PhD, BAppSc(Medical Technology) · Mary C Marshall BAppSc(Biology), GradDip Professional Communications

Improved leadership and recognising each others’ humanity are necessary for true health care reform I write this as an envoi immediately before my departure for a senior health position in Canada. Reflecting on my 35-year career in health care in Australia, I am concerned that, despite all the reform — which has been significant over this period, especially in reducing financial barriers to access — our health care sector still has not tackled fundamental challenges. The health system has been adept in responding to technological change, but our track record in responding to sociological change is poorer, and this gives cause for concern for the future. Health care use varies with age, with health care use concentrated in the last few years of life — typically over the age of 75 years. In the next decade or so, those aged over 75 years will be “baby boomers”, replacing those who grew up or lived through the Great Depression and World War II. Baby boomers tend to have very different expectations of clinicians and health care facilities, and to have a greater sense of entitlement. Most will also be regular users of the Internet. So what does this mean? Meekly waiting for care will be a thing of the past. Grateful acceptance of “cattle class” in outpatient departments will also go. “Charity” care by public hospitals officially ended with the introduction of Medicare in 1975, and is not part of the baby boomers’ adult experience. Patronising care, and patients’ acceptance of whatever is on offer, will become a thing of the past. There will be increased expectations of provision of accurate, up-to-date information; frank discussion of choices, attendant risks and likely outcomes; and treatment consistent with contemporary recommendations known to the patient (at worst from the trashy magazines that still adorn waiting rooms, or Internet sites of dubious validity; at best from websites that provide evidence-informed endorsed care paths). These changes are already happening. When things go wrong, there is and will be increasing pursuit of openness about the reasons why. Changes are also occurring in the workforce: the “team” with the medical team leader is under challenge, with expectations of shared leadership and more egalitarian styles. Nurse practitioners, podiatric surgeons and others are encroaching on the previously sacrosanct medical turf. Unfortunately, medical students still seem to be acculturated into the old paradigm — they emulate what they see their superiors do and, in contrast with other students, grow less team-oriented over their course of study.1 For the past 12 months, I have had dual roles: involved in macro system improvement as a member of the National Health and Hospitals Reform Commission (NHHRC), and leading statewide reform (principally focused on hospital-level change) as chief executive officer of Queensland Health’s Centre for Healthcare Improvement. These roles have involved considering the broad architecture of Australia’s health system and the day-to-day reality of provider-level change. The interim report of the NHHRC proposed macro levers of change — changed incentives on hospitals through activity-based funding, and on primary health care through steps towards limited enrolment-based care.2 But these macro changes do not, and can not, change the internal workings of hospitals and other health facilities. Levers for that are in the hands of individual managers and staff, and are not amenable to change with the levers in the hands of the NHHRC. Yet it is internal organisational processes that have such a profound impact on the working lives of health sector employees, and in turn affect patients’ experiences of the care received. It is here that the provider-level reforms, such as those initiated by Queensland Health, are so important in setting a context for the interaction between the patient and the clinician (Box). The changes in Queensland Health were made possible by political commitment to respond to two external reviews of the health system stimulated by the events in Bundaberg.6 The government responded quickly to these inquiries with a significant injection of funds and a reform agenda. Queensland, of course, is not the only state subject to either adverse safety issues or external inquiries.7,8 Unfortunately, the recent Garling Inquiry9 does not appear to have stimulated the same fundamental reform in New South Wales that Queensland embraced. The macro changes proposed by the NHHRC would lead to improved rationality of Australia’s health care system, and position us better for the technological, demographic and epidemiological challenges that confront us. Organisational changes, such as those being implemented in Queensland, help to create a better environment for the day-to-day workings of the system. But neither will guarantee the fundamental patient-centred reforms needed to respond to the sociological changes described above. Nor will they ensure that the micro environment of care, the interactions between clinicians and patients, between doctors and other health workers, will change. Of course, no health care system can guarantee perfect care and perfect outcomes for individual patients. It is inevitable that some health professionals will have a “bad hair day” — the result of activities the night before, work pressure, momentary distraction in thinking about issues at home or behaviour of their work colleagues. Even the best intentioned health professional can make a mistake. But it is these micro interactions that determine the patient experience, and tomorrow’s patients will expect more from their encounters and will be less tolerant of practices of the past. So what is to be done? Recognising the humanity of our patients and coworkers would be a start; as work interactions involve two people who are human, and equal in political and moral terms. So no pedestal, despite the information differential and the “sick role” that clinicians have traditionally expected of those they treat and care for. Improved leadership is also essential. Tolerance of temper tantrums is becoming a thing of the past. Dealing with aberrant behaviours is not enough. Leaders need to emphasise the importance of good communication between all partners in care, and provide the necessary training and time for this. Training for leaders is a sine qua non, as are systems to support leaders in the challenges they face. I expect Canada faces similar challenges, and I trust we can all learn from each other in transforming patient care. Provider-level change in Queensland Health, 2006–2009 Changing culture through the largest leadership development program in Australia (not only in the health sector), with more than 5000 managers and supervisors (just over half of whom were clinicians) participating in 2-day workshops to improve leadership skills; A reinvigorated clinical governance system to improve reporting of clinical incidents and near misses,3 to improve investigation of serious adverse events and to improve monitoring of performance to identify deviation from the state average;4 and An emphasis on the alignment of clinical governance with line management accountability.5

Stephen J Duckett PhD, DSc, FASSA

A key challenge for the Australian health care system is ensuring that the numbers, distribution and skill set of the health care workforce are adequate to meet the emerging health needs of an ageing population with increasingly high expectations of health care. Professional and government responses have given priority to increasing the overall numbers of practising clinicians by investment in additional training places. Another approach is to enhance productivity of the existing workforce by activating strategies of professional enablement that remove constraints imposed on clinicians by inefficient work practices and inappropriate training programs, maladaptive organisational attributes, misdirected financial and non-financial incentives, and adverse sociopolitical influences.

Ian A Scott FRACP, MHA, MEd

To the Editor: Climate change has an adverse impact on health.1 Procurement, waste production, transport, and energy and water consumption (ie, the ecological “footprint”) all contribute to climate change. If the principle underpinning the work of all health professionals is “do no harm”, addressing the harmful effects of the health care industry on the natural environment must become a priority. We argue that one way to rapidly achieve this would be to mandate more sustainable practices as part of hospital accreditation. The United Kingdom has specifically targeted its health system to reduce its large ecological footprint,2 but in Australia, progress towards environmental sustainability within health care is uncertain and unmonitored. The contribution by health care to Australia’s national carbon emissions is unclear, but we do know that, for example, Victoria’s public hospitals consume 60% of the total energy used by the state’s government departments,3 so we have the opportunity to make a major impact. There are excellent examples of hospital energy- and water-saving projects with financial recovery within 10 years.2,4 The Environment Protection Authorities of several Australian states are now mandating that heavy users of energy and water (including larger hospitals) have Environment and Resource Efficiency Plans to reduce their footprints,5 but action from hospitals has been unclear. Progress has typically been made on an ad-hoc basis by hospitals acting in isolation, although the Institute of Hospital Engineering, Australia is facilitating a more systematic approach.4 The Australian Council on Healthcare Standards (ACHS), through its Evaluation and Quality Improvement Program (EQuIP)6 accredits Australian hospitals against mandatory and preferred criteria. However, EQuIP does not currently include mandatory criteria that address issues such as energy, water and waste auditing, energy efficiency and the presence of a hospital environmental committee. The accreditation process offers an opportunity to encourage hospitals to prioritise these issues. The ACHS has awarded hospitals in the past for “environmental excellence”, but without a solid framework from the ACHS, the goal of all of our hospitals pursuing sustainability seems unlikely. In 2009, it is out of step with Australia’s shift to a low-carbon future that there are no requirements that hospitals achieve more sustainable use of energy, water and transport, and improve procurement and waste reduction. The introduction of broad environmental standards as part of the accreditation process could be a vehicle for achieving rapid improvements in sustainability across the hospital sector and shift our health system to one that “does no harm”.

Forbes McGain · Grant A Blashki · Kevin P Moon · Fiona M Armstrong

Handover is a ubiquitous feature of health care. At least 7 million handovers occur annually within Australian hospitals.1 At times, its very existence is almost unnoticed — many health professionals do not think of a telephone referral as “handover” — and at other times it is seen as a mundane chore that has to be done in addition to the “real” work of clinical staff. There can be complacency with current practices and little recognition of the high-risk nature of handover. Handover is noticed when things go wrong. One recent tragic failure was that of an elderly Aboriginal man left to die on an airstrip in the Northern Territory.2 The man had pneumonia and had been evacuated to Katherine Hospital. Before his evacuation, a nurse and district medical officer discussed the possibility of a family escort travelling with him. Although this had previously been recommended by his referring doctor, neither the acuity of the patient’s condition nor his personal circumstances (poor English and frailty) were clearly communicated, and no escort accompanied him. This was the first inadequate handover. After 9 days of treatment, he was discharged. The paperwork for his discharge was processed on a Friday, including a fax to his local community health centre advising of his scheduled Monday discharge. This fax was not seen or acted upon by the community health facility. Was this, then, handover at all? There was no checking system between the travel service and the community health centre, and it was presumed that there would be someone to collect the patient on his return from Katherine to the community. However, this was not the case. The patient was left by the pilot, alone at the airstrip some distance from town. On the Thursday, 3 days after the man was left at the airstrip, the police were informed that he was missing. His body was found the following Monday. He had died — alone, dehydrated and suffering from pneumonia. Since this tragic incident, the Northern Territory Government has taken steps to standardise and improve handover processes. The coroner’s report of the incident endorsed these steps as long as handover improvement was continual — the standardised processes would only be valuable if they were actively implemented and maintained. Problems that can arise from poor communication at handover include incorrect medications being given, delays in treatment or failure to give it, unnecessary repetition of diagnostic tests, and preventable readmissions. These failings waste time, strain health care resources and cause harm to patients. Health care professionals need to acknowledge that handover is a high-risk situation and that it is an element of their work that is integral to the delivery of safe patient care. Our own serious adverse events should not be the trigger for actions to standardise handover practice. We can learn from the mistakes of others to ensure safe transfer of information, responsibility and accountability in patient care. Clinical handover is defined as “the transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis”.3 Accountability and responsibility are critical terms in this definition, as “transfer of information is irrelevant unless it results in action that is appropriate to the patients’ needs”.1 When this governance view is taken of handover, the minimum required information elements and handover processes become more evident. Indeed, clinicians have a duty of care to ensure that effective handover occurs.4 The poor outcomes that arise from poor handover, as well as the scarcity of existing evidence,5 have motivated the Australian Commission on Safety and Quality in Health Care to work on developing evidence-based solutions for improving handover. The articles in this supplement are contributed by teams participating in the Commission’s National Clinical Handover Initiative. Each provides a view into how handover can be improved. There are several common themes addressed in these articles, which are described below. The need for “flexible standardisation”Although the concept of flexible standardisation may seem contradictory, teams have found that both flexibility and standardisation are essential. This may mean implementing a minimum dataset, such as SBAR (situation–background–assessment–recommendation) while still allowing for customisation to ensure that it meets the needs of the local clinical context. Several of the articles describe the implementation of different standardised tools for improving handover: Yee et al (on shift-to-shift clinical handover);6 Wood et al (on handover from inpatient private mental health care to the community);7 Clark et al (on improving communication between hospital staff at handover);8 and Belfrage et al (on handover from the aged-care home to the emergency department).9 The importance of clinician involvement in the quality improvement processMost of the articles touch, in some way, on the importance of engaging clinicians throughout the clinical handover improvement process. This ensures ownership of the process and a proper understanding of the local setting. User involvement is creatively addressed in the studies by Iedema et al (on enhancing communication to improve patient safety)10 and Porteous et al (on the design and testing of a comprehensive handover form).11 The former allows clinicians to create their own handover solutions, while the latter involves clinicians in the implementation of an existing standardised tool. Methods for ensuring that handover results in a shared understanding of informationAs handovers occur frequently in health care, understanding what each type of handover is for and how it should be presented is essential for ensuring confident and competent handover by all staff. A standardised approach to handover can help clarify the purpose and content of handovers and reduce confusion. Such an approach needs to be easy to use so it can be easily taught and recalled, as demonstrated by Hatten-Masterson et al in a study of enhancing clinical communication in a private maternity hospital.12 This point is also made in the article by Quin et al on standardised clinical handover tools,13 in which clinicians were informed of the dangers of poor handover. The article by Chaboyer et al on communication via whiteboards focuses on understanding how to use whiteboards in a systematic and planned way to improve handover.14 A shared understanding may also be promoted using technological solutions, as described by Silvester and Carr in a study of a shared electronic health record.15 The effects of health care culture and organisational structureThe complexity of health care means that maintaining the continuity of patient care is a challenging process. As the article by Botti et al on maximising patient safety in complex handover situations states, “it is unlikely that any one improvement strategy will be appropriate for all”.16 Training in communication within a team seems to be a helpful strategy, as demonstrated by Stead et al in a study of TeamSTEPPS (team strategies and tools to enhance performance and patient safety).17 This project used an existing program to train staff in using a standardised handover tool (SBAR) and in communication and teamwork in and around the handover. Some aspects of handover have been only tangentially addressed by the National Clinical Handover Initiative. It has been suggested that communication errors sit on the “dark side of measurement”,18 where less-developed measures mean that problems are ignored. We still know little about the measurement of safe handover practice. In addition, the significance of documentation (including letters and notes, some of which are held by the patient) and its relationship to verbal handover has not yet been adequately explored.5 Research on ways of using documentation to optimise handover is crucial to ensure that electronic records are designed to provide maximum safety for patients. Handover should be viewed as part of the provision of safe patient care, rather than as extra, unnecessary work. Good handover means that lapses in continuity of care, errors and harm will be reduced, whether patients are in the community or in hospital, undergoing a series of investigations, being prepared for surgery, recovering or dying. Clinicians and managers need to be aware that providing good handover requires an understanding of its purpose, leadership, protected time, a systematic approach, and a supportive clinical environment. Good handover takes effort.

Christine M Jorm MD, PhD, FANZCA · Sarah White BA · Tamsin Kaneen BA

It has been suggested that you can’t improve what you don’t measure. It has also been suggested that if you don’t know where you are going, any map will do. The articles in this supplement demonstrate that researchers in Australia are mapping approaches to measuring and improving the complex arena of clinical handover. Furthermore, their collective efforts at trying to make sense of the chaotic interlude of handover are at the cutting edge of clinical research. The focus on clinical handover is a relatively recent phenomenon in the grand scheme of quality and safety efforts. Interest in handovers has grown steadily over the past decade as researchers, hospital administrators, educators and policymakers have come to realise that the potential breakdown in communication during patient handover is a serious issue affecting their institutions, clinicians and patients. Indeed, the world has woken up to the fact that ineffective handovers are a hazard to patients, and result in misuse and poor utilisation of resources. Clinicians and researchers agree that handovers serve as the basis for transferring responsibility and accountability for the care of patients from outgoing to incoming health care teams across shifts, across disciplines and across care settings. Poor continuity of clinical care, either at a patient’s referral to hospital by a primary care provider or specialist, or at discharge from hospital, can be detrimental to the patient’s wellbeing. The exchange of information and responsibility that occurs during shift changes is critical for maintaining continuity and patient safety, and can often determine the ultimate outcome of care.1 System issues are at the heart of patient handovers — clinician-to-clinician communication, coordination of transitions and creation of mechanisms for feedback and feed-forward. The complexity of the handover process presents a series of “vulnerable gaps” in patient care that can result in errors, near misses and adverse events. Research has illustrated that there is little standardisation and great variation across disciplines and health care organisations in the ways in which handovers are performed.2-4 Unlike some areas that have been the focus of safety improvements, handovers of patient care are ubiquitous, cutting across all care settings and all disciplines. The World Health Organization listed “communication during patient care handover” as one of its “High 5” patient safety initiatives.5 Improving effective communication throughout the hospital is a leading patient safety goal espoused by The Joint Commission in the United States.6 The Australian Commission on Safety and Quality in Health Care (ACSQHC) has identified clinical handover as a particular focus for 2009.7 The call to action by the ACSQHC has been heard, and this MJA supplement represents a vibrant response from Australian researchers. Developing a single approach for all handovers is not possible because of the diversity and complexity of health care. Ensuring quality and safety during times of transition will therefore require an approach that draws on all available wisdom about what is needed to improve handovers, coupled with a systems approach to understanding and improving care at the point where patients and providers meet. The articles presented here examine handovers within and across multiple care settings (including residential aged-care facilities,8,9 inpatient care,10-15 mental health16 and maternity care17); handovers from community to hospital care;18 and the effects of different financing structures (public/private, state/federal).19 The projects described use a blend of qualitative and quantitative methods, including observations, interviews, focus groups, surveys, appreciative inquiry and case studies. In addition, the studies test several interventions to improve communication around the handover process: shared electronic health records, common datasets, educational interventions aimed at increasing staff awareness, checklists and whiteboards. Six recommendations emerge from the articles in this supplement and other cutting-edge work by a diverse set of researchers around the world. 1. Seek to understand handover communication as a complex adaptive processImproving outcomes requires an appreciation of the inherent link between explicit processes and results. Focusing on the system, rather than the individual, directs attention to the processes and outcomes of care without blaming or shaming individual people.20 2. Recognise the effect of culture as a key enabler for change and improvementThe culture of a care-giving unit underpins all processes and all improvements to care. Providers who are junior or new to the system may lack knowledge and confidence. For example, immigrants may be self-conscious about their command of the language and reluctant to ask questions. Lack of experience and the effects of a different cultural background are further exacerbated in settings with a steep authority gradient. 3. Develop tools to make information readily accessible and transparentDeveloping and maintaining decision aids requires an investment of effort and money. There may be a tendency to bypass such information documentation activities if easier avenues for securing information can be identified. Well designed, ergonomic solutions and consistent policies on the use of these resources increase the chances that such tools will be successfully adopted. 4. Apply principles of human factors to clinical designDesign workspaces that help reduce or eliminate interruptions during patient handover. Learn to appreciate the impact of the built environment and its impact on patient outcomes. 5. Focus on training and sustainingHandovers are rarely taught systematically. The following principles can help to redress this: Teach providers to tell a “better story”. More effective integration of the quantitative outcomes data with the more qualitative contextual data will enhance the wisdom of carers and capture the complexity of patient stories. Provide feedback. Sustain the effort by giving feedback about individual performance and by setting performance expectations. Couple inexperienced providers with experienced incoming and outgoing providers. The experienced incoming provider can demonstrate proper enquiries about patient status and issues, and the experienced outgoing provider can demonstrate proper “story-telling” and methods. Capturing the wisdom of an 8-hour shift is more complex than one might assume. Consider the use of videotaped simulated handovers and self-directed videotaping for reflexive learning. Use of these tools can improve handover. They can demonstrate the nature of false assumptions and omissions; the effects of interruptions; good versus poor patient problem descriptions; and the consequences of relying only on written information. 6. Identify the leadership required to improve handoversEffective leadership (at microsystem, organisational and national levels) is crucial for addressing systems issues and for creating the kind of “learning” organisation that is necessary for providing safer care. Several overarching themes can be gleaned from the articles presented in this supplement. Firstly, while standardisation of process and content are at the heart of effective handover, there is also a need for local customisation so that clinicians own and champion the handover process. This cannot be overemphasised. Front-line care-giving teams need to adapt standardised protocols to meet their needs, based on their unique set of constraints and enablers. Secondly, action research methods that bridge the gap between research and practice are an effective way to engage front-line staff in improving the handover process. Translating the recommendations of this supplement into practice will involve adapting them to local needs determined by the people, process and patterns at work in Australia. The proof in these and other proposed solutions comes down to implementation. In translational research, the handover phenomenon informs the research, and the research informs the practice. Questions to help guide local implementation of new handover strategies and to measure the impact of the changesWhat are the clinical handover situations that carry the most risk for patients? What information and critical success factors are needed to better understand the process of handovers in this setting? What handover interventions are the most effective? What resources and tools are available to improve handover communication? Which individual clinicians are willing to serve as “champions” for improving the handover process? What mechanisms can be put in place to spread, sustain and transfer improvements across the organisation? What improvements can be built into information systems tools to enhance their successful adoption (eg, checklists, reminder systems, information technology solutions)? Research funding bodies in Australia (such as the Australian Research Council and the National Health and Medical Research Council [NHMRC]) need to hear this message and consider allocating 2009–2010 research priorities accordingly. Action-oriented research emphasises the need for a highly collaborative and consultative approach between researchers and care-giving teams. As Iedema and colleagues state eloquently, “When enabled and trusted to develop and redesign work processes that make sense to them, clinicians gain ownership over the solutions proposed and designs instituted”.13 Handovers are high-risk scenarios for patient safety. In the end, patients will be safer only when clinicians are engaged and leading the change required around handovers.

Julie K Johnson MSPH, PhD · Paul Barach MD, MPH

A shared electronic health record system has been successfully implemented in Australia by a Division of General Practice in northern Brisbane. The system grew out of coordinated care trials that showed the critical need to share summary patient information, particularly for patients with complex conditions who require the services of a wide range of multisector, multidisciplinary health care professionals. As at 30 April 2008, connected users of the system included 239 GPs from 66 general practices, two major public hospitals, three large private hospitals, 11 allied health and community-based provider organisations and 1108 registered patients. Access data showed a patient’s shared record was accessed an average of 15 times over a 12-month period. The success of the Brisbane implementation relied on seven key factors: connectivity, interoperability, change management, clinical leadership, targeted patient involvement, information at the point of care, and governance. The Australian Commission on Safety and Quality in Health Care is currently evaluating the system for its potential to reduce errors relating to inadequate information transfer during clinical handover.

Brett V Silvester BEng, RegPM · Simon J Carr DipCS

Objective: To evaluate the use and usefulness of an aged-care home (ACH) transfer-to-hospital envelope (the Envelope) as a tool to support safe clinical handover when an ACH resident is transferred to an emergency department (ED).Design, setting and participants: Participants in the study were 26 ACHs (1545 beds), the EDs of six major metropolitan public teaching hospitals in Melbourne, and ambulance officers involved in transferring residents from ACHs to hospitals. Transfer data were collected over an 18-week period (January–May 2008). Evaluation methods included written surveys and semi-structured face-to-face interviews (interviewees were 19 ACH staff, 30 ED staff, and 7 ambulance officers familiar with the Envelope).Main outcome measures: Use, usefulness and ease of use of the Envelope; impact of using the Envelope on clinical handover; awareness of the need for clinical handover; sustainability of the project.Results: The Envelope was used for the large majority of ACH residents transferred to hospital (ACH data: 317/355 [89%]; ED data: 85/101 [84%]); 163/165 ACH staff (99%) thought the Envelope was useful, and 148/165 (90%) said it was easy to use; 128/165 ACH staff (78%) and all interviewees believed that using the Envelope improved clinical handover; and 152/165 ACH staff (92%) indicated they would continue to use the Envelope. All interviewees thought that using the Envelope had raised awareness of the need for clinical handover.Conclusion: The Envelope is useful and easy to use. It is used in the large majority of transfers of ACH residents to EDs and is highly valued by ACH staff, ambulance officers and ED staff. Our results suggest that use of the Envelope makes clinical handover safer for patients.

Mary K Belfrage MB BS, DRANZCOG, MPHAA · Clare Chiminello BA, GradDipLib · Diana Cooper RN, BAppSc(Nurs), GradDipHlthAdmin · Sally Douglas BAppSc(Phys), PostGradCertMHSC

Objective: To develop, using an evidence-based approach, a standardised operating protocol (SOP) and minimum dataset (MDS) to improve shift-to-shift clinical handover by medical and nursing staff in a hospital setting.Design, setting and participants: A pilot study conducted in six clinical areas (nursing and medical handovers in general medicine, general surgery and emergency medicine) at the Royal Hobart Hospital between 1 October 2005 and 30 September 2008. Data collection and analysis involved triangulation of qualitative techniques; 120 observation sessions and 112 interviews involving nurses and junior medical officers were conducted across the six clinical areas; information on more than 1000 individual patient handovers was analysed.Results: We developed an overarching four-step SOP and MDS for clinical handover, summarised by the acronym “HAND ME AN ISOBAR”. This standardised solution supports flexible adaptation to local circumstances.Conclusion: A standardised protocol for clinical handover can be developed and validated across professional and disciplinary boundaries. It is anticipated that our model will be transferable to other sites and clinical settings.

Kwang C Yee BMedSc(Hons), MB BS(Hons) · Ming C Wong BCom, MIS · Paul Turner BA(Hons), MSc, PhD

Objective: To describe and evaluate the PACT (Patient assessment, Assertive communication, Continuum of care, Teamwork with trust) Project, aimed at improving communication between hospital staff at handover.Design, setting and participants: The PACT Project was conducted between April and December 2008 at a medium-sized private hospital in Victoria. Action research was used to implement and monitor the project, with seven nurses acting as a critical reference group. Two communication tools were developed to standardise and facilitate shift-to-shift and nurse-to-doctor communication. Both tools used SBAR (situation, background, assessment, recommendation) principles. All nurses attended workshops on assertive communication strategies and focused clinical assessment of the deteriorating patient. Questionnaires were distributed to nurses and doctors at baseline, and post-implementation questionnaires and qualitative data were collected from nurses immediately after the project.Main outcome measures: Nurses’ opinions of improvement in structure and content of handover; nurses’ confidence in their communication skills.Results: At baseline, 85% of nurses believed communication needed improvement. After implementation, 68% of nurses believed handover had improved and 80% felt more confident when communicating with doctors.Conclusion: Early evidence supports the use of standardised communication tools for handover, together with specific training in assertive communication and patient assessment. Long-term evaluation of patient outcomes is needed.

Eileen Clark BA, MLitt, MSocSc · Sally Squire RN, BEd, GradDipMgt · Anne Heyme RN, GradCertOrthoNurs · Mary-Ellen Mickle RN, RM, BHS(Nurs) · Eileen Petrie RN, PGDipCPN, PhD

Objective: To determine whether there is an association between compensation factors and health care utilisation following major trauma.Design and setting: Retrospective cohort study within a major metropolitan trauma centre in New South Wales.Participants: Major trauma patients aged ≥ 18 years, admitted between May 1999 and April 2004. Patients were included if they had an accidental injury and an Injury Severity Score > 15. In total, 355 of 582 potentially contactable patients returned completed questionnaires (response rate, 61%).Main outcome measure: Health care utilisation, defined as the number of times patients visited specified health care professionals (general practitioners, medical specialists, psychiatrists, physiotherapists, chiropractors and massage therapists) in the previous 3 months. For statistical analysis, health care utilisation was dichotomised into low and high (0–3 or ≥ 4 health care visits over the previous 3 months).Results: Health care utilisation was significantly higher for patients engaging the services of a lawyer (odds ratio, 3.3; 95% CI, 2.0–5.5; P < 0.001) after allowing for time since injury, chronic illness, presence of a head injury and employment status. Having a head injury and increased time since injury were significantly associated with lower health care utilisation, whereas being unemployed and having a chronic illness were associated with higher health care utilisation.Conclusion: Compensation-related factors are significant predictors of health care utilisation in a major trauma population.

Ian A Harris MB BS, MMed(ClinEpid), PhD · Darnel F Murgatroyd MScHSci(ManipPhysio), DipPhysio · Ian D Cameron MB BS, PhD, FAFRM · Jane M Young MB BS, MPH, PhD · Michael J Solomon MB ChB, MSc, FRACS

Objective: To evaluate the effectiveness of the implementation of a TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) program at an Australian mental health facility.Design, setting and participants: TeamSTEPPS is an evidence-based teamwork training system developed in the United States. Five health care sites in South Australia implemented TeamSTEPPS using a train-the-trainer model over an 8-month intervention period commencing January 2008 and concluding September 2008. A team of senior clinical staff was formed at each site to drive the improvement process. Independent researchers used direct observation and questionnaire surveys to evaluate the effectiveness of the implementation in three outcome areas: observed team behaviours; staff attitudes and opinions; and clinical performance and outcome. The results reported here focus on one site, an inpatient mental health facility.Main outcome measures: Team knowledge, skills and attitudes; patient safety culture; incident reporting rates; seclusion rates; observation for the frequency of use of TeamSTEPPS tools.Results: Outcomes included restructuring of multidisciplinary meetings and the introduction of structured communication tools. The evaluation of patient safety culture and of staff knowledge, skills and attitudes (KSA) to teamwork and communication indicated a significant improvement in two dimensions of patient safety culture (frequency of event reporting, and organisational learning) and a 6.8% increase in the total KSA score. Clinical outcomes included reduced rates of seclusion.Conclusion: TeamSTEPPS implementation had a substantial impact on patient safety culture, teamwork and communication at an Australian mental health facility. It encouraged a culture of learning from patient safety incidents and making continuous improvements.

Karen Stead BN, RM, MBus · Saravana Kumar BAppSc(Physio), MPhysio, PhD · Timothy J Schultz BSc(Hons), GradDipPubHlth, PhD · Sue Tiver RGN, RPN, BNurs · Christy J Pirone BSN, RN, MCISc · Robert J Adams MB BS, MD, FRACP · Conrad A Wareham BM, FRCA

Clinical handover is an area of critical concern, because deficiencies in handover pose a patient safety risk. Redesign of handover must allow for input from frontline staff to ensure that designs fit into existing practices and settings. The HELiCS (Handover — Enabling Learning in Communication for Safety) tool uses a “video-reflexive” technique: handover encounters are videotaped and played back to the practitioners involved for analysis and discussion. Using the video-reflexive process, staff of an emergency department and an intensive care unit at two different tertiary hospitals redesigned their handover processes. The HELiCS study gave staff greater insight into previously unrecognised clinical and operational problems, enhanced coordination and efficiency of care, and strengthened junior–senior communication and teaching. Our study showed that reflexive and “bottom-up” handover redesign can produce outcomes that harbour local fit, practitioner ownership and (to date) sustainability.

Rick Iedema BA, MA, PhD · Eamon T Merrick RN, BHSc, MHSM · Ross Kerridge MB BS, FRCA, FANZCA · Robert Herkes MB BS, FRACP · Bonne Lee MB BS, FAFRM, MMed · Mike Anscombe MB ChB, FRACP, FACEM · Dorrilyn Rajbhandari RN, GradDipClinNurs · Mark Lucey MRCPI, FCARCSI, FJFICM · Les White FRACP, MRACMA, MHA