Health services administration

Objectives: To compare results of statistical process-control analyses of in-hospital deaths of patients with acute myocardial infarction by using either administrative or clinical data sources and prediction models, and to assess variation in results according to selected patient characteristics.Design: Retrospective, cross-sectional study comparing variable life-adjusted display (VLAD) curves derived by using administrative or clinical prediction models applied to a single patient sample.Participants and setting: Data from 467 consecutive patients admitted to a tertiary hospital in Queensland, between 1 July 2003 and 31 March 2006, with a coded discharge diagnosis of acute myocardial infarction.Main outcome measure: Statistical estimates of cumulative lives gained or lost in excess of those predicted at the end of the study period.Results: The two prediction models, when applied to all patients, generated almost identical VLAD curves, showing a steadily increasing excess mortality over the study period, culminating in an estimated 11 excess deaths. Risk estimates for individual patients from each model were significantly correlated (r = 0.46, P < 0.001). After exclusion of misclassified cases, out-of-hospital cardiac arrests and deaths within 30 minutes of presentation, replotting the curves reversed the mortality trend and yielded, depending on the model, a net gain of three or seven lives. After further exclusion of transfers in from other hospitals and patients whose care had a palliative or conservative intent, the net gain increased to seven or 10 lives.Conclusion: Appropriate patient selection is more important than choice of dataset or risk-prediction model when statistical process-control methods are used to flag unfavourable mortality trends suggestive of suboptimal hospital care.

Ian A Scott FRACP, MHA, MEd · Peter L Thomson MEngSc, MPH, MBiomedE · Seshasayee Narasimhan MB BS

The preceding papers in this supplement have described the stress in public hospital health care, the methods and application of clinical process redesign, and the substantial improvements achieved through redesign for both patients and staff. Here, we outline the key criteria for successful use of this clinical process redesign in both implementing and sustaining improvement. NSW Health and Flinders Medical Centre (FMC) in South Australia have been undertaking clinical process redesign projects since August 2004 and November 2003, respectively. In response to local needs and conditions, there have been variations in the way these redesign projects have been carried out. The common principles for successful implementation and sustainability that have emerged from our experience are listed below. They are supported by evidence from overseas programs undertaking similar reforms, particularly the National Health Service in the United Kingdom1 and the Institute for Healthcare Improvement in the United States.2 Leadership by the chief executive and senior managementVisible involvement of the chief executive and senior management is essential.3 Senior management needs to set the standards for service delivery and drive the change process. This requires management to engage and challenge staff with “stretch goals” (ambitious goals that stimulate staff beyond their current achievements), set the parameters for acceptable solutions, ensure strategies are implemented within set timeframes and budgets, monitor performance, and reward success. Staff members need to see that the program is a priority for their chief executive officer. To succeed in the face of obstacles and setbacks, resistance, or failure of certain elements of the project, senior managers need to be resilient and keep the momentum going. The experience at FMC (→ Redesigning care at the Flinders Medical Centre: clinical process redesign using “lean thinking”)4 has highlighted the significant benefits of having the executive team at hospital level directly involved in the redesign. FMC found it valuable to have senior clinicians and executives involved in tracking patient journeys and in clinical work. This has helped take redesign from being a project to being part of what staff do every day. In New South Wales, regular visits to clinical redesign sites by the NSW Director-General of Health and the NSW Minister for Health have been found to be a powerful motivator for staff, as these visits indicate that clinical process redesign is a high priority. Engaging clinical leadersClinical process redesign is not about changing clinical practice, but it does change the system of care delivery. Thus, clinical leadership is critical to success. A very important factor in engaging clinicians is for management to commit in advance to implementing the solutions designed by staff. Trust is gained when staff see their solutions being implemented; not implementing the solutions identified by staff, we feel, can lead to further cynicism. To commit to implementation, management must set the criteria for solution development in advance, and state what resources are available. If an expensive solution is proposed, staff need to understand that they will be required to justify the expense and ensure there are not less costly ways of achieving the desired result. Solutions that lie within current resources should be implemented immediately, and changed if they are not effective. Ensuring that increased safety is an outcome of redesign is attractive to clinicians, as is making the essential steps in a patient journey work more efficiently for staff. Clinicians have a vested interest in simplifying frustrating clinical processes and in eliminating waste. Involving clinicians in analysing the problems and developing the solutions should be done in a manner that meets their needs as busy professionals with limited free time — for example, short meetings at times when most are available. Multidisciplinary team solution designRedesign is best owned and managed by a workgroup comprising people who actually do the work, supported by those with redesign expertise. The workgroup must be given the time and the resources to gather and analyse the data, develop interventions, then plan the implementation and monitor its impact. ImplementationImplementation of the solutions is the hardest part of the process, and managers need to be given the necessary change management skills. There are professional courses available for managers on how to introduce change, and external consultants can give advice and coaching on this subject. Focus on the patient journeyA core focus of the clinical redesign process is the patient journey for groups of patients with similar service delivery needs. These groupings are broader than disease-based classifications. They are defined by grouping together patients with similar journeys, such as patients who visit the emergency department and then return home, frail older patients with multiple comorbid conditions, or relatively fit patients in hospital for day-only procedures. Understanding patient demand and standardising patient journeys will assist in simplifying the redesign process, so that the steps in a journey are readily known and understood by staff and able to be easily communicated to patients. Standard processes (a “lean thinking” concept5) are robust in design, less prone to error and are easy to teach to new staff. They should become second nature to staff and be easily integrated into information technology systems. Patients and carers as part of the teamPatients and carers must be involved in both defining and solving problems. In our projects, many innovative solutions have come from patients with no health care expertise. The patient journey should be designed to meet patient and carer needs, and the quality of the journey must be an outcome measure. We need better measures of the patient experience to include in the evaluation of redesign projects. DataSolutions need to be evidence-based. The process of redesign involves seeking stakeholder views on the problems and their causes, and then testing their opinions against available data. This helps resolve the problem of having multiple individual opinions or conflicting opinions as to the cause of a problem and its possible solution. The use of evidence also ensures that the selected solutions have a higher probability of being successful. This process builds trust with staff and confidence in management, and ensures time is not wasted trying inappropriate solutions. Rigorous monitoring of redesigned processes against set targets is essential to confirm that the intervention is achieving its goals. The data need to be simple, clearly visible to all stakeholders and available in real time so that problems can be analysed and corrected. Monthly data available 2–3 weeks after the end of the month are simply of no use. Clinical process redesign requires real-time information on a daily, weekly and monthly basis. Sometimes it is even required on an hourly or continuous basis. While some of the necessary data can be collected on paper or in simple databases, the redesign process has highlighted the need for much better data management systems. Ultimately, we have learnt that information technology systems that deliver relevant information to frontline managers are essential for achieving high-quality, efficient patient journeys (Box 1). Targets and timeframesThe desired outcomes for the patient journey need to be “stretch targets” — that is, ones that seem difficult to achieve. We have found this is essential to stimulate real innovation, as it challenges participants to think “outside the square”. Fear of failure is a major obstacle in this process, but we have found the excitement and pride staff feel when they realise what can be achieved with current resources is a powerful motivator in sustaining the program. Achievement inspires even further innovation and truly amazing results can be seen. It is very rewarding to observe a real sense of pride among health care staff who have improved the quality of their service. Managing the process — internal versus external managementAs outlined in other articles in this supplement, both NSW Health (→ Patient journeys: the process of clinical redesign)6 and FMC (→ Redesigning care at the Flinders Medical Centre: clinical process redesign using “lean thinking”)4 created a central group to manage their overall redesign programs. In NSW, this involved many hospitals across the state, whereas FMC is a single medical centre. In both places, there was recognition that the redesign process was a method that had been widely and successfully applied in other industries5 and there was a need to learn from or directly involve experts in redesign. FMC staff attended an external course to learn the redesign principles, whereas NSW Health engaged external consultants. The NSW statewide project delivered a significant return on this investment for NSW Health by reducing length of stay for patients. In both cases, strong program management, both centrally and at the level of individual projects, was essential. In NSW, the use of external facilitators (→ Patient journeys: the process of clinical redesign)6 was a powerful tool in breaking down the “silo” mentality and facilitating multidisciplinary teamwork. Their expertise in change management and in establishing data charts was exceptionally helpful in driving change. It was also essential to get the process up and running in multiple sites, where management and clinicians were often uncertain as to the benefits of the program. Organisational readinessWhen is an organisation ready for redesign? In our view, if there are acknowledged problems with access, flow, safety, waste or patient outcomes, it is time to act. It is easier to act and change mindsets through demonstrating that things can be improved than through waiting until there is general agreement that redesign could work. Health professionals have many opinions, all deeply and passionately held, and the impossibility of reconciling these views without evidence to the contrary is one of the biggest barriers to reform in health care. We have found that the key to organisational readiness is leaders who believe that things have to change. Selection of projectsIn our experience, it is best to start the redesign process with a problem that obviously needs to be fixed (eg, access block or ambulance diversion). Quick wins on high-profile problems engage staff and breed success. Improvements of the patient journey for high-volume patient groups, such as emergency medical cases, will also reap benefits, because improving efficiency in this group releases more capacity back into the system than improvements for lower-volume patient groups. Complete patient journeys are often complex, and can rarely be redesigned in one stroke. It will normally take a number of projects over time to comprehensively remodel a major patient journey. However, substantial improvements can be achieved with a well executed initial project, and this will build support for further improvements. Some projects are simple and straightforward (eg, standardising the layout of ward storage areas to remove the need for staff to learn the locations of essential equipment in each ward). Other projects are more complex and may involve more than one hospital. Each will require a different approach to engaging staff and implementing changes, and will need different timeframes. Local versus system-wide reformThe type of clinical process redesign methods we have described in this supplement work best at local hospital or unit level. A different approach is required to simultaneously run redesign projects across a number of hospitals. Nevertheless, our experience has shown that it is possible to do this with careful planning and well coordinated central program management. This has been demonstrated by the experience in NSW Health, by the Department of Health in the UK1 and in the “100 000 Lives” campaign of the US Institute for Healthcare Improvement.2 Knowledge sharing between teams was essential. It was achieved through workshops, online communities of interest and through the database of the Australian Resource Centre for Healthcare Innovations.7 Persistence and flexibilityIt does not matter which improvement method or model (lean thinking,5 six sigma,8 or theory of constraints9) is used in the redesign process, as long as it is applied with rigour and persistence. We have found that there needs to be constancy of purpose by all those involved in clinical process redesign. It is important to recognise that the redesign projects are not controlled trials, but are more akin to action research10 in that they are not designed to be perfect or dictated by strict protocols, but rather to be iterative and flexible as the need arises. In fact, it is crucial to their success that they are modifiable in response to data, as well as to staff and patient feedback. The plan-do-study-act11 method (testing a change by planning it, trying it, observing the results, and acting on what is discovered) is ideal for a flexible improvement model and allows reflective learning from one intervention to feed into the next. SustainabilitySustainability involves an ongoing improvement process. It should be a process of continuous review and improvement of health service delivery to meet a set of agreed standards. It needs to be embedded to become part of normal business for a health care organisation, not a series of one-off projects or crisis-driven reform programs. Sustainability, in our experience, is the most challenging phase of clinical process redesign. It is best depicted as a staircase, which demonstrates the notion that redesign is, by nature, continuous (Box 2). With this in mind, how should we approach sustainability? Our view is that it should be thought about as a dynamic process containing three main elements — standard work, maintenance and continuous improvement (Box 3). Standard workStandard work occurs at the end of successful implementation. The new processes (standard work) must be documented, and various roles defined and made explicit, especially with new or temporary staff. An important part of standard work is removing variation in the way a process is done. The performance of individuals and the team must then be monitored to ensure procedures are being performed as expected (Box 4). MaintenanceMaintenance of the improved standard work is an important element of sustainability. A process owner needs to be assigned to each redesigned patient journey. This person is required to “care” about and review the redesign work on a regular basis. Performance on relevant targets and key performance indicators must be regularly measured and tracked. The process owner will need to spend time in the workplace to observe how things are being done and identify opportunities for further improvements. Maintenance is essential within health care because of the dynamic nature of the workforce. The turnover of trainee staff is extremely high, and this can result in a breakdown in standard work. Maintenance of redesign work ensures that the improved practices become embedded, despite the changing nature of the clinical teams. Continuous improvementGrowing demand and technological change requires us to constantly improve to maintain standards. A regular forum where performance and process issues are discussed with stakeholders from across the patient journey is an ideal mechanism to promote ongoing improvement. The output of these forums should provide the next opportunity to redesign and improve the journey (Box 5). ConclusionClinical process redesign holds much potential. It has already demonstrated that it is a powerful tool for improving the systems that underpin health care service delivery. It has provided benefits for patients and staff by enhancing access and patient flow, and increasing safety, as well as improving the experience and health outcomes for patients. 1 Immediate access to performance information Web-based technology has been shown to be highly effective in providing real-time information (including process control charts for triage times and access block) to key managers in Sydney West Area Health Service in New South Wales. Managers have found that the additional cost of providing the data required is a small price to pay for the resulting major improvements in the quality of services. 2 The “staircase” of sustainability 3 The cycle of sustainability 4 Example of the standard work element of sustainability in process redesign at Flinders Medical Centre At Flinders Medical Centre, a standard process has been developed for writing discharge summaries, and this is used as a basis for intern orientation. It is displayed visually at each computer in the doctors’ offices and is included in the clinical handbook for each clinical division. 5 Example of the continuous improvement element of sustainability in process redesign at Flinders Medical Centre Within general medicine at Flinders Medical Centre, the junior doctors, consultants, department head and the redesign team meet every 2 weeks over lunch to review performance in regard to the redesign work, and to identify problems and improvement opportunities. This meeting is also an ideal mechanism for identifying, on a regular basis, the internal system problems that this group of clinicians face every day.

Katherine M McGrath FRCPA, RCPA, MRACMA · Denise M Bennett RM, BN, MBA · David I Ben-Tovim PhD, MRCPsych, FRANZCP · Steven C Boyages PhD, FRACP, FAFPHM · Nigel J Lyons BMed, MHA · Tony J O’Connell MB BS, FANZCA, FJFICM

Demand, as reflected in emergency department attendances, rose in all hospitals (range, 5%–27%) and surgical activity rose 2% across NSW over this period, yet performance on emergency and elective access indicators improved or was steady in 85 of the 95 possible instances for the four outcomes presented. Patient volume increases Outcomes Hospital ED attendances Admissions through ED Projects EAP* Triage 3* Triage 4* Long-wait elective surgery list† St George ↑ 18% ↑ 16% • Emergency patient flow; • Discharge planning; • Mental health emergency access; • Acute coronary care syndrome; • Ambulance case distribution ↑ 16 ↑ 23 ↑ 19 475 to 0 St Vincent’s ↑ 26% ↑ 29% • Emergency patient flow; • Discharge planning; • Mental health emergency access; • Acute coronary care syndrome; • Ambulance case distribution ↑ 11 ↓ 3 ↑ 4 195 to 0 Prince of Wales ↑ 18% ↑ 25% • Emergency patient flow; • Discharge planning; • Mental health emergency access; • Acute coronary care syndrome; • Ambulance case distribution ↑ 13 ↑ 17 ↑ 13 303 to 0 Sutherland ↑ 20% ↑ 28% • Emergency patient flow; • Discharge planning; • Acute coronary care syndrome; • Ambulance case distribution ↑ 22 ↓ 2 ↑ 10 Data unavailable Wollongong ↑ 18% ↑ 16% • Emergency patient flow; • Discharge planning; • Acute coronary care syndrome ↑ 20 ↑ 24 ↑ 16 15 to 3 Royal North Shore ↑ 18% ↑ 18% • Emergency patient flow; • Discharge planning; • Mental health emergency access; • Acute coronary care syndrome; • Ambulance case distribution; • Redesign of booked surgery ↑ 5 ↑ 3 ↑ 5 70 to 11 Bankstown ↑ 27% ↑ 13% • Emergency patient flow; • Discharge planning; • Mental health emergency access; • Ambulance case distribution; • Redesign of booked surgery ↑ 34 ↑ 8 ↑ 16 264 to 0 Concord ↑ 19% ↑ 6% • Emergency patient flow; • Discharge planning; • Mental health emergency access; • Acute coronary care syndrome; • Ambulance case distribution; • Redesign of booked surgery ↑ 24 ↑ 4 ↑ 9 175 to 0 Campbelltown ↑ 27% ↑ 6% • Emergency patient flow; • Discharge planning; • Mental health emergency access; • Acute coronary care syndrome; • Ambulance case distribution; • Redesign of booked surgery ↓ 2 ↑ 14 ↑ 12 332 to 0 Liverpool ↑ 22% ↑ 45% • Emergency patient flow; • Discharge planning; • Mental health emergency access; • Acute coronary care syndrome; • Ambulance case distribution; • Redesign of booked surgery ↑ 10 ↑ 21 ↑ 16 219 to 0 Royal Prince Alfred ↑ 20% ↑ 34% • Emergency patient flow; • Discharge planning; • Mental health emergency access; • Acute coronary care syndrome; • Ambulance case distribution; • Redesign of booked surgery ↑ 12 ↑ 14 ↑ 8 79 to 0 Lismore ↑ 13% ↑ 13% • Emergency patient flow; • Discharge planning ↓ 2 ↑ 13 ↑ 17 149 to 0 Port Macquarie ↑ 21% ↑ 2% • Emergency patient flow; • Discharge planning ↑ 5 ↓ 3 ↓ 2 227 to 0 Tweed ↑ 5% ↑ 43% • Emergency patient flow; • Discharge planning ↓ 12 ↑ 5 Steady 63 to 5 The Children’s Hospital at Westmead ↑ 22% ↑ 16% • Emergency patient flow; • Discharge planning; • Redesign of booked surgery ↑ 9 ↑ 21 ↑ 23 25 to 0 Blacktown ↑ 18% ↑ 11% • Emergency patient flow; • Discharge planning; • Ambulance case distribution; • Redesign of booked surgery ↑ 18 Steady ↑ 5 25 to 4 Newcastle Calvary Mater ↑ 16% ↑ 20% • Emergency patient flow; • Discharge planning Steady ↑ 4 ↑ 4 Steady at 0 John Hunter‡ ↑ 12% ↑ 18% • Emergency patient flow; • Discharge planning; • Mental health emergency access; • Acute coronary care syndrome; • Ambulance case distribution; • Redesign of booked surgery ↑ 21 ↑ 30 ↑ 32 15 to 0 Belmont ↑ 11% ↑ 16% • Emergency patient flow; • Discharge planning; • Redesign of booked surgery ↑ 11 ↑ 5 ↑ 8 Steady at 0 Dubbo ↑ 8% ↑ 3% • Emergency patient flow; • Discharge planning; • Redesign of booked surgery ↓ 4 ↑ 3 ↓ 5 Steady at 0 Gosford ↑ 9% ↑ 6% • Emergency patient flow; • Discharge planning; • Acute coronary care syndrome Steady ↑ 7 Steady 367 to 39 Westmead ↑ 24% ↑ 23% • Emergency patient flow; • Discharge planning; • Mental health emergency access; • Acute coronary care syndrome; • Ambulance case distribution; • Redesign of booked surgery ↑ 11 ↑ 31 ↑ 28 23 to 0 Nepean ↑ 22% ↑ 21% • Emergency patient flow; • Discharge planning; • Mental health emergency access; • Acute coronary care syndrome; • Ambulance case distribution; • Redesign of booked surgery ↑ 12 ↓ 3 ↑ 4 537 to 0 ED = emergency department. EAP = emergency admission performance (% of admissions through ED who egress from the ED within 8 h). Triage 3 = triage 3 performance (% of patients in triage category 3 whose treatment is commenced within 30 minutes of arrival). Triage 4 = triage 4 performance (% of patients in triage category 4 whose treatment is commenced within 60 minutes of arrival. * Percentage point change (eg, improvement from 63% to 75% is ↑12). † Change in the number of patients who have waited more than 365 days for surgery. ‡ John Hunter outcomes data cover the period commencing in 2002, as redesign commenced earlier in this hospital. Source: Tony Dunn, Director, Data Analysis and Performance Evaluation Branch, NSW Health, December 2007.

Glossary Action research: research undertaken by teams that is flexible and iterative; the aim is to problem-solve in order to improve the way processes are performed and services are delivered. Clinical process redesign: a health care improvement method that involves the redesign of the processes and services underpinning clinical care to make them safer and more efficient for patients and more satisfying for staff. Clinical silos: clinical specialties, subspecialties or geographical locations within which care is provided without regard to other components of the overall patient journey through a medical facility. Continuous improvement: continuous and incremental improvements to clinical processes achieved by removing unnecessary activities and variations, so that each state is the starting point for the next step on the journey towards the ideal state. Diagnostic phase: the phase of clinical process redesign that involves mapping the patient journey, identifying and prioritising the problems and validating the findings with relevant data. Implementation: the application or realisation of clinical process redesign on a patient journey. Lean thinking: a method that focuses on service provision in the most efficient manner by improving flow and eliminating waste from processes. Maintenance: actions undertaken to keep a redesigned process operating. Outliers: patients admitted to an available bed in a ward that is not the designated ward for their condition, because of congestion in the wards and the emergency department. Patient-care family: a functional group of patients who share a large proportion of clinical process steps regardless of their illnesses. Patient journey: the primary perspective in clinical process redesign; all the sequential steps in providing a patient’s clinical care; it includes the movement of a patient (from emergency department to ward or x-ray department) and the movement of a sample or document relating to the patient (eg, blood specimen, medical record, etc). Plan-do-study-act cycle: a quality improvement method consisting of the four continuous steps, plan, do, study and act, aiming to test a change by planning it, trying it, observing the results, and acting on what is discovered (also known as the Deming cycle or Plan-do-check-act cycle). Process mapping: documenting the patient journey, not as the ideal, but as it is, and involves confirming it with data. Process owner: a staff member is assigned to maintain and review a redesigned patient journey on a regular basis. “Pull” bed management: ward staff following a structured approach to identify patients in the emergency department who best fit their ward profile and then “pulling” those patients from the emergency department to their ward, rather than having to take any patient just because the ward has a bed available. “Push” bed management: wards taking patients from an overflowing emergency department just because there are beds available. Root-cause analysis: analysis of the original cause for variability or waste in a process. Segmentation: grouping patients into patient-care families (which have a common set of care processes) and treating each family separately. Six sigma: a systematic method for improving the operational performance of an organisation by eliminating variability and waste (“sigma” stands for standard deviation from the mean in a normal distribution). Standard work: the standard way of undertaking a sequence of care after the best, most efficient and most effective way of undertaking a care process in the patient journey has been established and agreed. Stretch goal or target: an ambitious goal or target that stimulates the team or institution to achieve far beyond their current capability. Sustainability: actions undertaken to maintain a redesigned process. “Take” system: a roster system involving hospital teams being rostered to take what may be large numbers of unplanned arrivals and process those patients. Theory of constraints: a method for identifying and overcoming key bottlenecks and constraints which inhibit an organisation achieving its goal. Value stream: the sequence of steps that add value to patient care within a patient-care family.

To the Editor: Predicting research quality on the basis of past research publications is clearly imprecise, as noted by Nicol et al in their recent article on National Health and Medical Research Council (NHMRC) grant applications.1 They note that assessor ratings of applicants’ “track records” correspond poorly with the bibliometric data for authors, and that there is vast variability between discipline panels. For immunology, the correlation between track record scores and journal impact or citations was high, at over 0.7. For public health, the correlation was actually negative. The authors consider some possible reasons for the wide discrepancies, such as poor coverage of public health publications in the journals captured by Institute for Scientific Information citation indexes. Nevertheless, they are at a loss to explain why the variation is quite so great, and conclude by suggesting that the time is right for an automated approach to assessing quality. We need to consider the implications of this suggestion carefully. Track record within NHMRC project grants is assessed relative to opportunity, with regard to factors such as legitimate career interruptions, administrative and teaching load, and typical publication rates for the field in question. In the fellowship or program grants schemes, there appears to be less emphasis on relativity, which may explain some of the closer correspondence between actual and expected citation rates. We need to be clear that the use of an “automated” system that uses surrogate measures of research quality will disadvantage individuals who experience a period of illness, take maternity leave, change their research area, or carry a period of heavy administrative or teaching load, as well as those who publish books, book chapters or government publications. It will also disadvantage teams in which feasibility requires fieldwork collaborators whose applied work does not readily translate into peer-reviewed journal publications. For instance, much public health research is based in the community or takes advantage of data collections in the public health system. Collaborators working in this context often have relatively limited opportunities for peer-reviewed publication. Nevertheless, their active collaboration is often critical for achieving a feasible research plan. Also disadvantaged would be teams with a new or junior investigator, particularly if the new team member was the first named investigator. On the other hand, a move to an automated system of quality assessment would further advantage grant applicants who work in research-dedicated institutes, those engaged in basic research, and those who do not require external collaboration. Given these reservations, I suggest further investigation, by discipline, of what makes a “good” track record, before recommending a single assessment formula.

Michael J Davies

To the Editor: It is a worthy aspiration for Australia to become the world’s healthiest country, but it will take revolutionary leadership to prevent and manage the effects of obesity that will reverse the previous gains in reducing heart disease.1 In addition, we have to overcome the adverse impact on the health of young people caused by fundamental changes in Australia, highlighted by Eckersley.2 He also identifies medical practitioners as a potential obstacle in that we are overfocused, with government approval, “on an individual, biomedical, disease-centred approach to health at the expense of a more social, preventative model”. He also calls for an increase from the current investment in prevention and public health programs, 1% of health expenditure — but that will only occur if his more radical suggestion is adopted: that governments change their focus from wealth to health creation. It was Japan that embraced this concept, with a health creation policy developed in 1978. It led to a law ensuring that at least 5% of their compulsory health insurance expenditure is allocated to preventive activities. If we are going to achieve Ring and O’Brien’s vision, we are going to have to do more than adopt Japan’s healthy diet. Other keys to their success are: good antenatal care; reinforcement of high breastfeeding rates by provision of small incentive payments; routine home visits to women during pregnancy and during the postpartum period by maternal and child health care workers; and all parents having their own maternal child health record. While these and other measures have probably contributed to Japan having the lowest infant mortality in the world, these interventions are also likely to have influenced their longevity by preventing the Barker hypothesis from being applied. This hypothesis, or developmental origins theory, was derived from observations of infants who are small at birth being at higher risk of increased blood pressure and other adverse cardiovascular endpoints later in life.3 It is interventions during the early years that have evidence of high returns on investment — whereas attempts to influence adult behaviour are difficult, and can fail.4,5

Bret Hart

In reply: Our paper demonstrates the considerable potential for improving Australia’s already competitive international mortality ranking by focusing on several selected conditions and inequalities in their distribution among Australians.1 Hart recognises the aspirational nature of the paper and proposes several challenges and opportunities to improve the health of the mothers, babies and young children of Australia. We agree. As shown by our evidence, Australia’s performance on mortality in infancy and early childhood is less than stellar. We acknowledge that our ranking on some childhood risk factors, such as obesity (which can confer lifelong health disadvantage and may affect future mortality), may well be similar or even worse. A critique of these was beyond the scope of our paper, as we confined our analysis to measures of past mortality. There is ample evidence of effective interventions for infants, children, adolescents, adults and older people, and for various population groups. The interventions include preventive or clinical services — as the Journal’s own repository of guidelines shows.2 We contend that rather than being alternatives, childhood and adulthood interventions are complementary (as are biomedical and social interventions), and we have to advance simultaneously on many fronts. Australia has accelerated to be among the world’s leaders on mortality and life expectancy, but, as Hart presages, this will not remain the case merely through a continuation of current trends. It may take a revolution, but we can at least be clear about how we compare in these areas and what we need to achieve.

Ian T Ring · John F O’Brien

An integrated comprehensive approach to medication error is a national imperative Medication errors are among the most common incidents reported in public hospitals.1,2 This is not surprising, given that every admitted patient receives some medication. If medication is one of the hallmarks of treatment in our institutions, it, more than any part of our practice, should be made safer and, wherever possible, error-proof. In New South Wales public hospitals, the Incident Information Management System (IIMS) report for 2005–20063 included 17 367 medication incidents in which medication error was the primary cause of harm. In another 968 incidents, medication error was a secondary cause. Most incidents were notified from the services of general medicine or pharmacy, but all clinical services, including surgery, reported medication errors. The severity of most reported medication errors is minor. In the IIMS report, less than 0.3% of notified medication incidents in NSW were given a severity assessment code of 1 (SAC 1), compared with 0.8% SAC 2, 25.9% SAC 3 and 56.2% SAC 4 (SAC 1 = severe harm; SAC 4 = trivial or no harm). In this issue of the Journal, Nichols and colleagues4 examine medication errors and highlight the types and context of errors at Fremantle Hospital, Western Australia (→ Learning from error: identifying contributory causes of medication errors in an Australian hospital). Although the study was based on a small sample, its principal strength was that it examined not only the incident but also the environment, the team, the tasks being undertaken, and the individual circumstances of those “responsible” for the error. The study cohort was selected by pharmacists during regular ward rounds over a 6-month period. Fremantle Hospital participates in the Australian Incident Monitoring System and has patient safety committees. The Fremantle Hospital study did not give error rates, but the IIMS data3 suggest that the problem of medication errors is not small. We need to reinvigorate attempts to provide secure prescribing environments. Practitioners must be able to concentrate, without distraction, on the patients for whom they are prescribing. They must have adequate information on the indications for prescription, potential complications, contraindications and drug interactions of the prescribed medications. Nichols et al reported that 7/26 members of staff (27%) indicated there was lack of guidance from senior colleagues when they were prescribing unfamiliar medications, 8/26 (31%) were dealing with an unfamiliar patient when the error was made, and 5/26 (19%) were working in an unfamiliar ward! Hastily scribbled notes during a rushed ward round from a senior consultant who presupposes competencies to a newly posted intern are not a prescription for safety, but a recipe for error! Root-cause analysis data from NSW5 have shown that major factors leading to severe incidents (SAC 1) include deficiencies in policy (25%), communication (25%) and knowledge/competency (18%). These data are consistent with the study of Nichols et al, in which poorly defined policies or inadequate drug information were found to be a factor in 23% of medication errors. In the Fremantle Hospital experience, communication within the team was a factor in medication errors in 31% of incidents, and communication with others was also a factor in 31%. Various initiatives that may lessen the risk of medication errors in Australian hospitals require more evaluation. The National Inpatient Medication Chart,6 commissioned by the Australian Council on Safety and Quality in Health Care, is an important advance. All junior staff now know where to prescribe, how to look for and how to document medication. This evidence-based best practice initiative, led by the Safe Medication Practice Unit of Queensland Health, addresses key problems, such as the prescribing and dispensing of warfarin. It is important that the national initiative not be undermined as individual hospitals, units or clinicians make local modifications. Rather, local lessons must contribute to the national debate and the standard document should be improved by consensus. Standardised formats for multiple-drug protocols must also be developed. Many hospitals do not yet use electronic prescribing. The drug advice available to junior staff often consists of a dilapidated, torn and hard-to-find MIMS publication that is often many months out of date. Although MIMS is now available online in all public hospitals (except in South Australia), and NSW Health has a state licence for personal digital assistants (PDAs) for all staff, neither technology (online or PDA) is fully utilised in the public sector. Other electronic sources of drug information available include the “Therapeutic guidelines” series (http://www.tg.com.au/index.php?sectionid=97), the Australian medicines handbook (http://www.amh.net.au) and the Clinical Information Access Program (http://www.ciap.health.nsw.gov.au). Whatever the technology or software used, it is essential that teams develop, with hospital pharmacists, relevant orientation procedures, including information on medication usage, for new members of the team. Medication reconciliation7 (the formal process of obtaining a complete and accurate list of each patient’s current home medications and comparing the clinician’s admission, transfer or discharge orders with that list) and pharmaceutical review8 (the systematic appraisal of all aspects of a patient’s medication management to optimise patient outcomes) provide opportunities for minimising “slips and lapses”, but are not yet seriously “on the radar”. Multidisciplinary hospital drug committees could provide local champions for such programs, collect and evaluate data and develop the evidence base. These issues demand systematic attention from hospitals, administrators and clinicians. The NSW Therapeutic Advisory Group and the Clinical Excellence Commission (NSW) have adapted a Medication Safety Self-Assessment (MSSA) tool developed by the Institute for Safe Medication Practices (ISMP) in Canada and the United States for use in the Australian health care environment.9 A similar antithrombotics tool10 addresses the critical issues around the narrow therapeutic index of antithrombotic medicines. These tools, which are complementary to the Indicators for quality use of medicines in Australian hospitals,11 allow hospitals to assess their own performance and provide national information about safe medication use. Their effectiveness in reducing medication harm is yet to be proven in Australia. The ISMP MSSA tool was evaluated in the US12 in 2002 and again in 2004. Collaborating members did demonstrate continuing improvement in key elements of medication safety (Cohen MR, Vaida AJ. ISMP Medication Safety Self-Assessment — Australian version: experience in the United States. International video conference launch of MSSA. Sydney: ISMP, Feb 2007 [unpublished]). These and other tools could enable all clinicians to measure medication practice, monitor new protocols and minimise the types of slips, lapses and incidents reported in the study by Nichols and colleagues. An integrated comprehensive approach to medication error is a national imperative. We should not be afraid to compare and contrast systems, as long as designs allow an interface between core national and state platforms. Nichols and colleagues have given the problems of medication error human faces — both staff and patient. Only serious system-wide measurement and evidence-based change can return smiles to those faces!

Clifford F Hughes AO, FRACS, FACS, FACC

Suffering and healing in America: an American doctor’s view from outside. Raymond Downing. Oxford: Radcliffe Publishing, 2007 (xii + 126 pp). ISBN 978 1 84619 130 5. In an age of increasing disparity between the health systems of rich and poor countries, Suffering and healing in America offers an analysis of how America’s health system can learn from the achievements of those in more poorly funded settings. The author argues that health care in America risks the charge of hubris as it increasingly fails to address the needs of poorer members of the community. Furthermore, Western medicine has so raised the expectations of cure that it has contributed to the loss of capacity to cope with suffering when cure is not possible. He discusses the comparative notions of cure and healing and the evolving role of family medicine within the health care system. While many of the questions the author raises are undoubtedly serious challenges facing health care and therefore worthy of discussion, his subjective analysis rarely penetrates far below the surface of the more complex issues. The author makes heavy going of his cure versus healing discussion but never really mounts a clear argument. The way he uses anecdotes to illustrate certain points is reminiscent of parables, and too often they shed little light on the labyrinthine world of modern health care. The chapter on culture offers perhaps the most pertinent example of this, leaving the reader frustrated by the simplicity of the analysis. The title of the book is itself a curious example of the false trails the author follows: he spends more of the book discussing his experiences as a medical practitioner in Africa than America, and not all the comparisons he makes are relevant given the cultural, social and economic disparities between the two worlds. The repeated pattern of raising topical issues but then not really addressing them undermines the value of the book as anything more than a mildly interesting narrative.

Damien W Morgan

Objective: To study the clinical contexts contributing to harmful medication errors.Design, setting and participants: A qualitative study using semi-structured interviews was conducted between March and August 2005 at Fremantle Hospital, a 450-bed metropolitan teaching hospital. Twenty-six of 46 staff members (57%) identified by pharmacy staff as having contributed to a significant medication error were interviewed. Interviews were recorded and transcribed for thematic analysis.Results: Most errors were due to slips in attention that occurred during routine prescribing, dispensing or drug administration. Knowledge-based mistakes (eg, failure to follow a protocol) also contributed to prescribing errors. Errors were more likely to occur during tasks being carried out after hours by busy, distracted staff, often in relation to unfamiliar patients. Communication problems with senior staff and difficulty accessing appropriate drug dosing information contributed to knowledge-based prescribing errors. Several medical staff were unaware they had committed an error until their involvement with our study.Conclusions: Contextual factors that contributed to slips, lapses and knowledge-based mistakes in our sample are likely to be widespread in hospitals, and their impact on medication error may be substantial. Staff need training in how to recognise and deal with error-prone clinical situations. Safe prescribing practices (eg, the absolute requirement to acquire information before prescribing unfamiliar drugs) must be emphasised. Improved access to drug information at the point of prescribing, attention to communication barriers, and increasing staffing levels in particular areas are other potential strategies for reducing error.

Pamela Nichols PhD · Tandy-Sue Copeland DipPharm · Ian A Craib MB ChB, MRCP, FRACP · Paul Hopkins · David G Bruce BSc, MD, FRACP

Objective: To audit the accuracy of dose administration aid (DAA) packaging in regional aged care facilities (RACFs) within the boundaries of the Hunter Urban Division of General Practice.Design, participants and setting: Each participating RACF audited one DAA for each resident receiving medication between May and August 2006. Registered nurses compared the contents with the medication chart prepared by the general practitioner and recorded any discrepancies as incidents.Main outcome measures: Number of medication incidents in the provision of DAAs.Results: 297 incidents were detected from 6972 packs for 2480 residents (incident rate of 4.3% of packs and 12% of residents) from 42 participating RACFs. Reasons for incidents included medications missing from a pack (99 occasions), wrong medication dispensed (12), supply of the wrong strength (32), incorrect labelling (7), pharmacies supplying medication that had been ceased by the GP (37), incorrect dosage instructions (32), medications not delivered to the RACF (13).Conclusion: The rate of incidents in DAA packaging in RACFs was high. The error types included incorrect packaging, correct packaging but the DAA was no longer required, and operational problems. Recommendations for improvement include: continuing audit and analysis by RACFs; streamlining of communications among GPs, pharmacists and RACF staff; using electronic methods to chart, order and dispense medications; use of generic names as much as possible; development of guidelines for the supply of medication in DAAs.

Annette Carruthers MB BS(Hons), FRACGP, FAICD · Kialie Naughton · Gordon Mallarkey PhD

To the Editor: Australia, like many other nations, is experiencing an epidemic of overweight and obesity. The most recent National Health Survey reported that 62% of men and 45% of women were overweight or obese.1 Among numerous associated concerns is the cost burden of obesity-related illnesses on individuals, the community and the health system. Among the 45–54-years age group (the stage at which osteoarthritis becomes a significant health problem), we calculated the population attributable risk (PAR) for osteoarthritis associated with obesity to be 25% for men and 22% for women, using a relative risk (RR) of 2.4 and obesity estimates of 23.3% for men and 20.1% for women. In terms of major health sequelae of the epidemic, this is second only to obesity-related type 2 diabetes (RR, 3.2; PAR, 34% for men, 31% for women). Some obese patients will have multiple obesity-related comorbidities. In 2005 in Australia, 2551 national hospital separations among people aged 45–54 years were for obesity-related osteoarthritis.2 Using data from the three most recent National Health Surveys, we projected the likely prevalence of obesity among 45–54-year-old Australians in 20251,3,4 and then estimated future hospital separations and direct health system expenditure, using costing information supplied by the Australian Institute of Health and Welfare.2 We project that in 2025, if Australians born between 1971 and 1980 maintain their current rate of weight gain, the proportion of obese 45–54-year olds will rise to 38.8% of men and 32.2% of women. The estimated number of hospital separations for obesity-related osteoarthritis will increase to 4216. The direct health system cost (in current dollars) will rise to $44.4 million, from an estimated $25.5 million in 2005. The 45–54-year-old population comprises a considerable proportion of the workforce, and obesity-related illness impacts on absenteeism5 as well as individuals’ and families’ quality of life. As the current generation of young adults ages, a trend toward increasing illness arising from high levels of obesity is likely, unless health and government policy initiatives to prevent weight gain are given higher priority.

Margaret A Allman-Farinelli · Robert J Aitken · Lesley A King · Adrian E Bauman

To the Editor: I write in response to two articles published recently in the Journal.1,2 Both propose that substitution of doctors with paramedical professionals is reasonable. I disagree. I think it is imperative that before doctors decide to only see the “fun” patients, we had better be sure we want to surrender our status in the health care system. In the report by Oldmeadow and colleagues,1 as a result of workload constraints, the proposition is made to have physiotherapists run and manage an orthopaedic clinic. By the patient-to-doctor ratio in the study, the average load per week for each doctor was four new and five old patients in a 3-hour clinic. Perhaps readers will compare that load with their own. The study’s outcomes are a cause for concern. Recommendations for management and treatment by two physiotherapists were compared with those of an orthopaedic surgeon. If the surgeon’s opinion is deemed to be correct, then over 25% of the patients who attended these clinics would have been treated incorrectly. In addition, 13% of the physiotherapists’ assessments were not only wrong, but the management plans did not include referral to the surgeon. Remember, this was a highly artificial, simplified clinic treating a limited range of conditions. Consider what the error rate would be in an open clinic with no restrictions on the patients to be seen. In the same issue of the Journal, Smith and Baird proposed that radiographers are qualified in some way to read images.2 While radiographers are skilled technicians, in no way would their interpretive skill be equal to that of a general practitioner, radiologist, or consultant in any other specialty. We should not lower standards for the sole reason of speed of access. I would advocate focusing on consolidating the education of GPs, and so empower them as a group. GPs with special interests could equally act as the gatekeepers to clinics. It is unfair to foist the decisions on care, which are our duty, onto other professionals who are not as extensively trained as we. The job of a surgeon is not to operate on patients. It is rather to organise the care of patients who have a problem in the area of our specialty.

Jeffery M Peereboom

In reply: Peereboom appears to ignore reality. Recent news media1 gave an insight into the state of radiological services at some Sydney teaching hospitals. Thousands of images have never been seen by a radiologist. Yet, all of those images were seen by radiographers, who also saw the patients. I am frequently asked by doctors for my opinion about radiographs. At times, I volunteer my opinion to junior doctors and general practitoners. Thirty years of experience tells me that, if I don’t, they miss abnormalities, delaying treatment and decreasing the quality of care. Peereboom will have worked with radiographers capable of accurately interpreting radiographs. Today, many Australian radiography students have tertiary entrance scores in the 90s. Arguably, the only reason we cannot teach them to formally give their opinion on radiographs is because of a professional boundary drawn in the sand in the 1920s.2 However, the sand is shifting under the health care system. I have the greatest respect for radiologists’ knowledge, skills and intellectual capacity. However, an advanced practice role for radiographers is not just about respect. It is a human resource issue. Knowing that the current service model is antiquated, do we wish to limit the potential of both radiographers and radiologists in the future?

Tony N Smith

Teleradiology is like a “two-edged sword” that requires careful consideration and balancing, needing uniform standards to guide quality care while ensuring patient safety The rapid and secure transfer of x-ray and diagnostic imaging studies around the world is being facilitated by new technologies, such as picture archiving and communication systems (PACS), high-speed Internet access, and secure virtual private networks. This transfer of images, usually for assessment by a radiologist at a geographically remote site from where the images were obtained, is known as teleradiology.1-4 Domestic and international teleradiology is practised by individuals and imaging practices (private radiology groups and corporate practices), as well as teleradiology groups in Australia. Based on the 2006 Royal Australian and New Zealand College of Radiologists (RANZCR) Workforce Survey,5 about 67% of Australian radiologists use teleradiology in their daily work: 92% within their own state, 22% between states, and 1.7% internationally. The international teleradiology workflow is bidirectional, with Australian imaging studies being reported overseas and overseas imaging studies being reported in Australia. Clinical teleradiology has advantages, but there are also potential problems and pitfalls. However, in teleradiology, as in any use of radiology, the provision of high-quality, appropriate clinical care and accountability must remain of utmost importance, and this principle should guide teleradiology’s further development. In Australia, there is an escalating demand for diagnostic imaging services. The RANZCR anticipates that demand will greatly outstrip current supply in the radiologist workforce for at least the next 5 years. Further, this ever-increasing demand on diagnostic imaging services is accompanied by an increasing complexity of studies and a continued expectation that they will be reported promptly, 24 hours a day, 365 days a year. Given the geography and demographics (including radiology workforce demographics) of Australia, the benefits of using teleradiology are clear. Teleradiology can provide remote interpretation for rural and regional communities; second subspecialist opinion; workload balancing for diagnostic imaging staff; education; research; and clinical/quality audits.6,7 Out-of-hours interpretation, when local radiology services are unavailable, may also be of great benefit to patients if urgent advice is required. Similarly, however, several potential pitfalls are evident. One key pitfall relates to the “distancing” of the radiologist from patients clinically, as well as geographically — a trend that is already increasing with onsite services, and may only intensify with teleradiology. Radiologists have minimal influence over referrals that occur under a capped diagnostic imaging Medicare budget for billed services or in the public hospital sector. Apart from technological considerations, current legislation, reimbursement schedules and workload demands also exacerbate the increasing distancing of radiologists from clinicians and patients. Reporting radiologists may have little or no clinical or contextual patient information or direct communication with the clinician caring for the patient, resulting in image interpretation occurring in isolation, rather than provision of an integrated expert opinion. However, if this pitfall is avoided, specialist radiologists can make a pivotal contribution to clinical decision making and management — clinicoradiological discussions can result in a change of clinical diagnosis in 50% of cases and a change in treatment in 60% of cases discussed.8 Using radiologists and diagnostic imaging wisely could reduce the burden on the entire health system by not only improving diagnosis and management but also by reducing unnecessary and repeated radiation exposure, thus optimising overall patient care. Other potential problems relate to technical and professional considerations. Transfer of images may result in less than optimal image quality, hampering interpretation. If images are sent overseas, it is possible that the reporting radiologist may not be trained to the same standard as radiologists in Australia. We need to acknowledge that when English is not a radiologist’s primary language, there may be increased potential for error. Indemnity may not be guaranteed, and protection for patients may not be available.2-4,6,9,10 Perhaps the most serious concern relates to the potential evolution of medical services, including teleradiology, as commodities instead of community services. The globalisation of health care has never been more evident than in international teleradiology. The emerging globalisation of health care generally1-4,11 and, more specifically, the progressive corporatisation of radiology providers and the prospect of commoditisation of radiology services9,12 are on our doorstep. To contain cost, maximise efficiency and meet shareholders’ expectations, health care providers increasingly use teleradiology to outsource services.3,4,9,12 In some countries, out-of-hours on-call teleradiology has fully matured, and teleradiology companies are turning to daytime and subspecialty segments to further grow their market share.9 Some observers have noted that teleradiology could be treated as a commodity and traded with forward contracts.12 This concept of forward trading of medical services seems to be quite divorced from more traditional philosophies of the practice of medicine, and, at the very least, the public at large and those who pay for these services should be made aware of this trend. From a community perspective, if teleradiology is viewed purely as a technical service, with no consideration given to the quality, appropriateness or relevance of the interpretation service, nor to patient safety; if it is driven purely by cost and workforce pressures, convenience, or desire for market share, then this would be highly undesirable. Even within Australia, it is possible that commercial leveraging may occur, resulting in disruption to local radiologists, the local clinical diagnostic imaging team, and community service provision if cost-cutting and market share are primary motives for the introduction or further development of teleradiology.2,9,13 Thus, where a local clinical radiology service exists, compelling advantages for patient care would need to be identified to justify the additional provision of teleradiology services. However, when teleradiology can facilitate good patient care, this is an excellent outcome of the application of this technology. Teleradiology, both domestic and international, can be considered a “two-edged sword”, requiring careful consideration and balancing. The rapid growth of teleradiology and the globalisation of health care have led to the need for a set of uniform standards to protect consumer rights, define responsibilities, enable inter-jurisdictional recognition, ensure quality and safety, and enable benchmarking.6,13,14 Accordingly, the International Radiology Quality Network (IRQN)13 has developed a set of international clinical teleradiology principles to guide quality care and ensure patient safety. Australian representatives actively contributed to this development, and the RANZCR has adapted the IRQN principles in a position statement applicable to Australia and New Zealand.15 In general, these principles emphasise that the entire focus of international clinical teleradiology (as for radiology in general) must be solidly based on “what is good for the patient”. For example: the correct imaging procedure should be performed; images should be of a high quality and transmitted accordingly; communication must be made between the treating team and the (appropriately credentialled and indemnified) radiologist, providing a high level of clinical information; images must be interpreted in light of the full clinical history and available previous imaging; and the radiologist’s interpretation of the images and medical opinion must be communicated clearly and in a timely manner. The position statement also addresses specific, serious concerns, including security (eg, sites should comply with all nationally specified data protection standards) and ethics (a system should be in place to document electronic “fingerprints” of interpreting radiologists, to prevent “ghosting” of reports). The position statement will be updated regularly, with additional input sourced from the RANZCR Quality Use of Diagnostic Imaging Program teleradiology projects and the RANZCR Standards of Practice and Accreditation Committee, as well as IRQN updates. Any practice or hospital considering the use of domestic or international clinical teleradiology will be well served to be guided by these principles, and must, at all times, maintain a principal focus on high-quality patient care. With time, the regulatory, legal and ethical framework applicable to teleradiology may well flow on to other medical disciplines.

Lizbeth M Kenny MB BS, FRANZCR · Lawrence S Lau MB BS, FRANZCR

The 35th Annual Physician Assistant Conference held in the United States in May 2007 provided an opportunity for Australia to learn from the experience of other countries The 35th Annual Physician Assistant Conference of the American Academy of Physician Assistants (AAPA), held in Philadelphia in May 2007, was attended by almost 8000 delegates, including physician assistants (PAs), students, academics and policymakers. The conference aimed to promote professional development of PAs, develop ideas and provide education. It also featured an international forum focusing on global developments in PA-related activities. We report here on two countries that have recently introduced PAs, to identify opportunities for improving Australia’s transition into implementing the PA role. Physician assistants: a possible solution to workforce shortage in AustraliaPAs are health care professionals licensed to practise medicine under physician supervision.1,2 They were introduced in the United States in the 1960s to alleviate shortage and maldistribution of primary care physicians. The PA role has now spread outside the US, with various levels of development underway around the world (Box).3-10 The role is now internationally recognised as part of a solution to the combined issues of health workforce shortage and increased demand for health care services.11 Several Australian groups, including public and private health providers in Queensland, the University of Queensland (Centre for Military and Veterans’ Health and the Centre for Health Innovation and Solutions) and James Cook University, are addressing medical workforce issues by piloting and advocating a PA-type role as one of many solutions.12,13 The international forum at the AAPA conference provided an opportunity for Australian delegates to learn from the experience of other countries that have undertaken similar projects. Of eight forum presentations focusing on new and emerging roles and experiences, those from Canada (Ontario) and Scotland were related to projects in pilot phases and were considered the most relevant to the Australian situation. The Ontario experienceJoshua Tepper (Assistant Deputy Minister, Health Human Resources Strategy Division, Ministry of Health and Long Term Care, Ontario, Canada) provided an overview of the progress of the introduction of the PA role into Ontario. A broad government initiative known as HealthForceOntario established a bold and aggressive plan to ensure the right number and mix of health care providers in communities across the province, and to establish new and expanded roles in areas of high need. Implementation of this plan included the following key steps: May 2006: Enabling legislation is enacted for the demonstration projects. June 2006: Consultation with all stakeholders, including employers, educators, regulators, health professionals (eg, medical, nursing and allied health staff at Ontario’s hospitals) and other experts (eg, Canadian Forces, University of Manitoba, Canadian Association of Physician Assistants, overseas medical workforce experts). August 2006: Selection of six hospitals willing to employ emergency care teams that include PAs and nurse practitioners (NPs). April 2007: Definition of competencies profiles and scope of practice statements for PAs to practise in Ontario. May 2007: Employment of PAs and NPs to work at the six selected emergency departments. Assessment begins concurrently and includes outcomes of care for specific diagnoses, patient waiting times, access to care, satisfaction with care, and satisfaction with PAs and NPs. The rapidity of this initiative’s progress is attributed to several factors: development of strong partnerships and collaborative relationships; support from other health professions and experts in the field; high acceptance of overseas-trained PAs participating in pilot projects; completion of a PA competencies document; and significant government investment in the PA initiative. Two elements are considered key. First, the PA role was already in place in the Canadian military as well as in the health care system in the province of Manitoba.7 This allowed policymakers to refer to current experiences within the country. Second, a Physician Assistant Implementation Steering Committee was established to collaboratively guide development, implementation and evaluation of all PA projects. The Steering Committee, co-chaired by two doctors and including a broad base of stakeholders (eg, PA experts and educators, and representatives from partner organisations, nursing, community clinics and academia), met monthly to facilitate communication. Six subcommittees and working groups were responsible for research and design of key components of the project, with a focus on: developing Ontario PA competencies; defining PA scope and role definition; determining compensation; establishing educational programs; addressing liability issues; establishing evaluation; launching demonstration projects in clinical settings; recruiting; and developing communications. With its combination of professional expertise, the Steering Committee overcame a number of challenges such as recruiting the required number of PAs, increased workload due to aggressive timelines, and concerns from other professions about the introduction of a new and unregulated profession. HealthForceOntario is committed to several demonstration projects that are introducing PAs to the Ontario health care system through a wide range of clinical settings and using a variety of employment models throughout the province. A combination of 88 hospitals and at least five community health centres have expressed interest in employing a PA, although only 40 PAs are being recruited. Until HealthForceOntario produces enough “home-grown” PAs, Ontario will recruit PAs with formal education from other jurisdictions, such as retired PAs from the Canadian Forces, and PAs from around Canada and the US who are eligible for Canadian PA certification. The Scottish experienceAt the 2006 AAPA conference in San Francisco, Scotland announced a demonstration project and actively recruited PAs for 20 positions. A total of 240 applications were received — 45 PAs were interviewed, 20 were offered contracts, and 12 American PAs arrived in Scotland to work on a 2-year contract. They are deployed in demonstration projects at various sites, in the areas of family medicine and emergency medicine.10 The leaders of the research team, Ricky Bhabutta (a British Army doctor, and Senior Medical Officer, Scottish National Health Service [NHS]) and Patricia O’Connor (National Clinical Coordinator PA Project, Scottish NHS), discussed the first 6 months of their demonstration project, which began in November 2006. One of the main challenges they faced was the logistics required in settling the expatriates into Scottish life and culture. Despite this, the successful aspects of their project included: Preparation for “cultural” differences of the workforce, the Health Department, the community, and the PAs themselves (eg, through media, local open days, leaflets, emails, conferences, teaching sessions, and hospital and regional awareness campaigns). Country induction using a specific relocation company allowed a smooth transition into Scottish life for the PAs. This included introduction to cultural and social aspects of living in Scotland, introduction to the NHS, and adaptation to British medicine and local programs. Central coordination and site selection provided by the Scottish Executive. Partnership with central (NHS) funding for evaluations, the recruitment process and awareness-raising events. Objective and structured behavioural interviews with the PA candidates. The University of the Highlands and Islands was commissioned to compile monthly evaluation reports for all sites. PA development days and opportunities for feedback into the project allowed for open discussions of difficulties with the project staff or supervisors. The PAs working in Scotland also reflected on their experiences and suggested some things they felt could be done differently. They proposed that a site visit would have allowed them to obtain a better set of expectations regarding the relocation and demonstration process. They felt that a lack of clarity of the job description provided a source of confusion and frustration, and that the recruitment period was too short. The lack of definition of the supervisor role also created some initial confusion. The supervisors and project managers added a few other aspects that could have been managed better, such as involving doctors in the recruitment process, establishing the supervisor role, reviewing the team role of the PAs in the context of major changes in the British medical training model, and obtaining positive media involvement. A perceived hurdle for Scotland is that the PA is not a registered profession in the United Kingdom. Consequently, the PAs are working under a delegation and referral clause. Discussions about further developing PAs for Scotland have been centred on the cost, the necessity, and whether it would be more economical to recruit them from England and North America or to start a university-based program in Edinburgh. The assessment team reflected on a number of observations from the first half of the 2-year experience. A needs assessment by a workforce scholar was deemed a necessity, as it provided a solid literature review on various roles and experiences in the US and Canada.10 For instance, it prevented the “name game” that England experienced (eg, “medical care practitioner” instead of “physician assistant”). Furthermore, drawing on American PA consultants, site visits, involving the citizenry of small towns, and attendance of conferences (eg, those of AAPA) were considered beneficial. According to Dr Bhabutta, it is only a matter of time before PAs are dispersed throughout the North Atlantic Treaty Organization (NATO) countries. Lessons learnedThe experience of these two Commonwealth countries gives some indication of how implementing a PA-type role in Australia can be successfully achieved in a timely manner. The outcomes of this important conference showed that strategies likely to ensure success include reviewing the literature and incorporating the following essential elements: an active steering committee composed of a broad base of stakeholders; legal discussion around enabling legislation and the delegation role of doctors in supervising PAs; a recruitment process, conducted by a professional agency, that draws on these lessons; and clearly defined roles for both PAs and supervisors. State of development of physican assistant (PA)-related activities around the world3 State of development Countries Development of civilian PA programs England,* The Netherlands,* Canada,* South Africa, Scotland,* Taiwan PA-like profession in place India, Liberia, Haiti, Malaysia Use of United States-trained PAs in the national health system Canada,* England,* Scotland,* The Netherlands* Hosting workforce development conferences in which PA profession is proposed The Netherlands,* England,* Germany, South Africa, Taiwan, China, Ghana Developing and establishing formal affiliation agreements with US PA programs for PA student rotation Brazil, Estonia, United Kingdom,* Ghana, Thailand, Honduras, Ecuador, China, Papua New Guinea, Costa Rica Seeking information on PA profession Australia,* Ghana, Ireland, Jamaica, New Zealand, South Africa, Wales * Represented at the 35th Annual Physician Assistant Conference.

Laurent A Frossard PhD · Genevieve Liebich · Roderick S Hooker PhD · Peter M Brooks PhD · Lynn Robinson MD

Objective: To determine the prevalence, staffing, methods, timing and allocation of bereavement programs in Australian palliative care services.Design: Questionnaire-based postal survey.Setting and participants: The questionnaire was mailed in January 2007 to all 324 palliative care centres identified from the Australian Palliative care national directory 2004.Results: 236 of the 324 centres responded (73%), and 95% of these undertook bereavement follow-up, with similar prevalence in metropolitan and regional areas. Staff from a range of disciplines were involved in coordinating and delivering these services, with nurses taking on these roles in most regional centres. Common types of bereavement follow-up included individual sessions and visits, telephone contact, letters, anniversary cards and memorial services. Most centres (74%) approached the bereaved within 2 weeks of the death, and 83% of centres offered bereavement support to families or “significant others” of all patients who died under their care. Some form of risk assessment for complicated grief was performed by 69% of participating centres.Conclusion: Bereavement care is an integral part of Australian palliative care services. Given the multidisciplinary staffing demonstrated, it is important that those coordinating and delivering these programs are adequately trained and supported. There is a need for further research to guide the development of bereavement support practice.

Mark A Mather BMed · Phillip D Good FRACP · John D Cavenagh FRCA, FAChPM, MMedSci(Epidemiology) · Peter J Ravenscroft MD, FRACP, FAChPM

The first aim of a medical registration scheme should be to protect patients. Medical registration boards currently offer variable information to the public on doctors’ registration status. Current reform proposals for a national registration scheme should include free public access to professional profiles of registered medical practitioners. Practitioner profiles should include: practitioner’s full name and practice address; type of qualifications; year first registered, and duration and type of registration; any conditions on registration and practice; any disciplinary action taken; and participation in continuing professional education.

Judith M Healy BA, MSW, PhD · Costanza L Maffi BSc(Hons), MSc, GradDipIT · Paul Dugdale MPH, PhD, FAFPHM

To the Editor: I am concerned that the Journal supplement “Early intervention in youth mental health”, published on 1 October 2007, may contravene the MJA policy on sponsored supplements. Item 9 of that policy (http://www.mja.com.au/public/information/instruc.html#Supplements) states: The supplement’s articles should not favour drugs/interventions/views/products of the supporting body to the detriment of other drugs/interventions/views/products. While many of the articles in this supplement are clearly scientific papers, a minority read more as advertorials and promote the interests of two of the supplement’s sponsors.1-3 The ORYGEN–headspace approach to adolescent mental health differs from the approach of other expert organisations, including the Faculty of Child and Adolescent Psychiatry of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) and the Australian Infant, Child, Adolescent and Family Mental Health Association.4 Both these organisations support ORYGEN and headspace in seeking to enhance mental health services and transition to adult services for adolescents, but not in the proposed “specialist youth-specific (12–25 years) mental health services providing comprehensive assessment, treatment and social and vocational recovery services”2 (Dr Phill Brock, Chair, Faculty of Child and Adolescent Psychiatry, RANZCP, personal communication). This arrangement does not fit with the way in which other service providers (education, juvenile justice, medicine) are organised, or with the legislative framework that protects the rights, welfare and safety of children (0–17 years of age). Children are not young adults, and child and adolescent mental health service models differ significantly from the traditional focus of adult mental illness. Most teenagers require a family-centred, developmentally appropriate, contextually sensitive, multimodal and systemic model that is less well developed in adult mental health services, including ORYGEN. In spite of claims to the contrary in the supplement, these different approaches are in competition for resources. ORYGEN and headspace have a product to sell (to government and to the medical and lay community). The publication of this supplement has provided them with a platform without presenting an alternate view.

Jon N Jureidini

In reply: Dr Jureidini’s response to the “Early intervention in youth mental health” supplement is puzzling and idiosyncratic. He asserts some kind of impropriety on our behalf or that of the MJA — an assertion we strongly reject. All articles were peer reviewed by experts in the field, including the editorial,1 which is obviously and explicitly the authors’ point of view and therefore open to debate, which we welcome. Other articles Jureidini characterises as “advertorial” are genuine descriptions of new models of care.2,3 Far from selling a product, we are advancing legitimate clinical and scientific arguments, and describing active reforms in mental health. Our “interests” are the pursuit of better mental health care and outcomes for young Australians, pure and simple. No evidence is provided for the assertion that the models described are in competition for resources. headspace has been fully funded with a completely new allocation of federal resources, with no funding redirected from other programs to support it. Furthermore, the youth mental health reform model was selected by the Australian Government through a nationally competitive tender process, in which anyone with a different approach was free to put it forward; indeed, several other submissions were considered and rejected. Similarly, no resources have been diverted to create the ORYGEN model; it is simply a successful restructure of existing resources that is demonstrably better accepted and more effective. Evidence shows that young people and their families find services structured in this way much more user-friendly, and levels of access, engagement and retention are substantially increased over traditional models. One of us (P M) is a member of the Faculty of Child and Adolescent Psychiatry of the Royal Australian and New Zealand College of Psychiatrists (RANZCP), and neither we nor headspace are aware of any official position of the RANZCP that is inconsistent with or unsupportive of the headspace development. Most of the 30 new headspace services across the nation are being established in partnership with local child and adolescent psychiatrists and public mental health services. While many psychiatrists are supportive of and working within the headspace and ORYGEN models, a small subset have expressed a fear that strengthening the focus on adolescents and young adults will somehow disadvantage children. Where is the evidence to support this fear? We are wholly supportive of further investment and improvement in mental health services for children. Unnecessary division on this issue will hamper all progress and is against the interests of patients and families. We strongly agree that there is clearly unmet need in the 0–12-years age group, as well as a further need for preventive interventions beyond the clinical service system, which may in time reduce the surge of incident cases of adult-type disorders. We call on Dr Jureidini to put his efforts into increasing resources and developing innovative service models to improve the mental health of both children and young people, rather than engaging in sterile arguments over professional territory and distribution of existing resources that will benefit no-one.

Patrick D McGorry · Anthony F Jorm · Rosemary Purcell · Ian B Hickie

In reply: I welcome Dr Jureidini’s criticisms regarding the publication of the MJA supplement “Early intervention in youth mental health”.1 Dr Jureidini has two major concerns. First, a number of articles in the supplement are deemed to unilaterally advocate concepts arising from the ORYGEN–headspace program, with the suggestion that this exclusivity contravenes the MJA policy for publishing sponsored supplements. Second, he claims that the general framework of the ORYGEN–headspace program does not have the endorsement of professional bodies such as the Faculty of Child and Adolescent Psychiatry of the Royal Australian and New Zealand College of Psychiatrists (RANZCP). Eminent mental health experts reviewed the articles in the supplement and, interestingly, not one of these authorities raised the RANZCP’s misgivings. This could mean that propagation of the Faculty’s concerns in the psychiatry fraternity may be selective, or that the rationale for its position has not convinced psychiatrists at large. Dr Jureidini’s other concern — that the supplement favoured the ORYGEN–headspace approach at the expense of other interventions, views or products — reflects the very essence of supplements. The fundamental purpose of publishing research or commentaries is to enter information into the publishing–evidence–integration cycle, wherein the dissemination of evidence or ideas is intended to promote change by influencing other researchers, health care professionals, the public and, ultimately, policymakers. Indeed, the ORYGEN–headspace program must have influenced policymakers, as the federal government recently announced grants totalling $19 million to support the national roll-out of the headspace program, especially in rural communities.2 Even if the publication of the MJA supplement played little or no part in this political endorsement, I am content that it has, at least, fostered debate and may well play a part in improving mental health services for young Australians.

Martin B Van Der Weyden

Objective: To evaluate and compare the clinical outcomes of children with cystic fibrosis (CF) managed primarily at a tertiary cystic fibrosis centre (CFC) with those treated at regional centres by local health care professionals and the cystic fibrosis outreach service (CFOS).Design, setting and patients: Retrospective study of 273 children with CF born between 19 October 1982 and 19 February 2002 and with clinical data available between 1 January 2000 and 31 December 2002. Patients were grouped into CFC (n = 131) or CFOS (n = 142), with CFOS then further categorised into three groups depending on the level of care they received.Main outcome measures: Pulmonary function, Pseudomonas aeruginosa status, height and weight z scores, and hospital admission rates.Results: There were no significant differences in pulmonary function, P. aeruginosa status, or height and weight z scores between children managed by CFC or by CFOS. Children receiving more care at the CFC (level of care [LOC] 1 and 2) were more likely to have multiple hospital admissions than children receiving more care in regional areas (LOC 3 and 4) (P < 0.001).Conclusion: The CFOS model provides effective delivery of specialised multidisciplinary care to children and adolescents living in rural and regional Queensland.

Clare L Thomas MB BS, FRACP · Peter K O’Rourke BSc, BA, PhD · Claire E Wainwright MB BS, MD

More than three-quarters of Australia is classified as geographically remote. Remote areas are characterised by geographic isolation, cultural diversity, socioeconomic inequality, resource inequity, Indigenous health inequality, and a full range of extreme climatic conditions. Although several descriptive definitions have been developed for “remote health” and “remote practice”, definitions of “remote medical practice” or “remote medicine” have not been previously published. In 2007, a working group of doctors and academics with experience in remote medicine was formed to develop the first advanced specialised remote medicine curriculum for remote doctors undertaking training with the Australian College of Rural and Remote Medicine. The first step was to define remote medical practice. Remote medical practice has eight key features: employment rather than private practice, isolation, use of telehealth, increased clinical acumen, extended practice, cross-cultural setting, multidisciplinary practice, and an emphasis on public health and personal security. From these eight features, we developed the first working definition of remote medical practice in the Australian context. Our definition will assist policymakers, medical colleges, standard setters, and educators to develop programs and resources for the future remote medical workforce.

Janie D Smith MPHC, EdD · Stephen A Margolis DRANZCOG, FRACGP, FACRRM · Jeff Ayton AFFTM, DRANZCOG, DA · Victoria Ross MB BS, FRACGP, MPHTM · Elizabeth Chalmers FACRRM, ACRRM, AFPHM · Patrick Giddings FACRRM, FRACGP, DRANZCOG · Louise Baker FRACGP, DRANZOC, DCH · Martin Kelly MB BS, PhD · Catherine Love MB, FACRRM, FRACGP

Objective: To compare the national inpatient medication chart (NIMC) with the chart previously used at Royal Perth Hospital (RPH) in Western Australia, and with charts used at 13 other hospitals across Australia; and to audit NIMC performance in practice and to assess its design characteristics.Design: Audit of patient prescribing documents extended to include a comparison with aggregated pilot study data and the previous RPH chart. Assessment of design features by inspection, based on their likely effect on medication safety.Setting: A tertiary public hospital.Main outcome measures: Compliance with the requirements of chart fields, measured as the percentage of correct entries according to predetermined criteria as required by the WA Office of Safety and Quality in Health Care.Results: Average compliance was 56% (95% CI, 43%–67%). Differences in compliance after introduction of the NIMC were variable and only one was classified as “major”. The number of charts required per admission increased from 3.1 for the previous RPH chart to 6.3 for the NIMC, and chart replacement was required after 2.9 days for the NIMC compared with 5.5 days for the previous RPH chart. Of seven advantages of the NIMC claimed by the WA Director General of Health in a letter to doctors, five (71%) were not confirmed in practice. Ten notable design features of the NIMC with a potential adverse influence on medication safety were identified.Conclusions: The NIMC contains adverse design features and is inferior to the medication chart previously in use at RPH. The purported advantages of introducing a national standard chart were not experienced at RPH.

J Alasdair Millar PhD, FRACP, FRCP · Robyn C Silla BN · Glenda E Lee BN, PGDipClinN(CritCare) · Ann Berwick BPharm, PGDipPharm

Abortion law reform focuses on early abortion. Women wanting to have a family who have a fetal abnormality detected later in pregnancy are neglected in the debate and harmed by the consequences of current legal uncertainty. Unclear abortion laws compromise: the quality of prenatal testing; management when an abnormality is found; and patient care, through obstetricians’ fears of legal repercussions. Women carrying a fetus with an abnormality are being denied abortion, even when the abnormality is so severe that non-treatment would be an option if the baby were born. Many women are likely to refuse to consider motherhood if they are denied appropriate prenatal testing and access to abortion if serious abnormalities are detected. Current abortion laws result in discriminatory and inconsistent practices, where access to prenatal testing and termination of pregnancy depends on location, the values of the treating doctor or hospital ethics committee, and a woman’s personal resources. Legal certainty is needed to reduce the suffering of couples wanting to have a family.

Lachlan J de Crespigny MD, BS, FRANZCOG · Julian Savulescu MB BS, BMedSci, PhD