Nationally coordinated IPC initiatives – lessons learnt from the Australian experience John Ferguson August 2016 DRAFT
Nationally coordinated IPC initiatives –
lessons learnt from the Australian experience
John Ferguson August 2016
DRAFT
Overview
1. Australian Healthcare System – Structure, Process and Outcomes; reactive versus proactive approaches to system repair - adding the ‘Safety 2’ ethos
2. ACSQHC and other national programs & enablers
3. National Safety and Quality Healthcare Standards and Standard 3 – progress and challenges
Donabedian model
Donabedian’s Lasting Framework for Health Care Quality Ayanian et al, NEJM 2016: 375;205-6.
Structure- healthcare • Healthcare management structures in Australia
deficient in many key systems regarded as essential in high reliability industries: – Consistent staff competency assessment and re-
validation process – Accountability and governance – Standard operating procedures
• ISO 9001 quality management system specifies the essential cogs and wheels required
Preventing healthcare-associated infection: risks, healthcare systems and behaviour Internal Medicine 2009 574-581 Ferguson
Barriers impeding best practice
Kennedy-P et al. Med J Aust 2010; 193 (8): 97 National Institute of Clinical Studies. Identifying barriers to evidence uptake. Melbourne: NICS, 2006.
Outcomes - Australia: 2008 estimates
• 200,000 healthcare-associated infections per annum; 12,000 bloodstream infections
• 2,000,000 bed days lost : • Mortality: circa 5,000 per annum based on
international estimates
Australian Commission on Safety & Quality in Healthcare, 2008- Reducing harm to patients: the role of surveillance
Root cause analysis • Formal method used to analyse serious adverse events • Identify underlying problems that increase the
likelihood of errors, taking the focus away from mistakes by individuals.
• Causal statements are generated through event mapping and investigation of links between context, events, actions and patient outcomes.
• Ultimate goal – learn from error/mistakes - prevent future patient harm by proposing system changes
RCA Limitations • RCA effectiveness in lowering risk or improving
medical safety not systematically established • Quality of RCA dependent on accuracy of input data
as well as capability/experience /effectiveness of RCA team
• Open to political hijack • Accidents assumed to be caused by failures or
malfunctions.
Dixon-Woods et al. The Problem with RCA, BMJ Quality & Safety, 2016 Shaqdan K, et al Root-cause analysis and health failure mode and effect analysis: two leading techniques in health care quality assessment. J Am Coll Radiol. 2014 Jun; 11(6):572-9
• 2015 report: 6 preventable deaths 2012-April 2015, NSW
• 2 further deaths since then • 51 near-miss events
Preventing IV device morbidity: recurrent system issues
Structure Accountability & governance Staff competency Environmental controls Design of devices
Process Standardising insertion procedure & kit Aseptic technique- insertion and access Safe removal Documentation & detection of deteriorating patient Surveillance of patient outcomes Audits of process compliance
An alternative perspective on accident investigation
“Things basically happen in the same way, regardless of outcome. The purpose of an investigation is to understand how things usually go right as a basis for explaining how things occasionally go wrong.”
Hollnagel et al. From Safety 1 to Safety 2: A white paper, 2015
https://www.england.nhs.uk/signuptosafety/wp-content/uploads/sites/16/2015/10/safety-1-safety-2-whte-papr.pdf
How hazardous is healthcare? Dr. Lucien Leape National Patient Safety Network, 2004
Dangerous Regulated Ultrasafe (>1/1000) (< 1/100,000)
Total lives lost per
year
1
10
100
1000
10,000
100,000
1 10 100 1000 10,000 100,000 1M 10M
Bungee jumping
Mountain climbing
Healthcare (USA)
Driving
Chemical manufacturing
Chartered flights
Scheduled airlines European
railroads Nuclear power
Number of encounters for each fatality
‘High reliability organisations’ US Navy nuclear aircraft carriers, nuclear power plants, and air traffic control centres had these defining characteristics: • They were complex, internally dynamic, and,
intermittently, intensely interactive • They performed exacting tasks under considerable
time pressure • They had carried out these demanding activities
with low incident rates and an almost complete absence of catastrophic failures over several years
James Reason . Human error: models and management BMJ 2000;320:768–70
Paradoxes of high reliability • Traditional view: human unreliability attributed to
unwanted variability and strive to eliminate it as far as possible.
• High reliability organisations: recognise that human variability in the shape of compensations and adapta-tions to changing events represents one of the system's most important safeguards. Reliability is “a dynamic non-event.” Dynamic = safety preserved by timely human adjustments; Non-event = successful outcomes rarely call attention to themselves.
James Reason . Human error: models and management BMJ 2000;320:768–70
High reliability organisations
“Perhaps the most important distinguishing feature of high reliability organisations is their collective preoccupation with the possibility of failure. They expect to make errors and train their workforce to recognise and recover them. They continually rehearse familiar scenarios of failure and strive hard to imagine novel ones. Instead of isolating failures, they generalise them. Instead of making local repairs, they look for system reforms.”
James Reason . Human error: models and management BMJ 2000;320:768–70
Overview
1. Australian Healthcare System – Structure, Process and Outcomes; reactive versus proactive approaches to system repair - adding the ‘Safety 2’ ethos
2. The ACSQHC and other national programs & enablers
3. National Safety and Quality Healthcare Standards and Standard 3 – progress and challenges
ACSQHC Structure
• Established 2006 to lead and coordinate national improvements in safety and quality in health care
• National Health Reform Act 2011 (NHR Act) which established the Commission as a corporate Commonwealth entity under the Public Governance, Performance and Accountability Act 2013 (PGPA Act).
• Joint funding etc
Governance - Committee membership
Clinical experts
Implementation
Authority
Leadership
Priorities
HAI Advisory
Infection Control Guidelines
Antimicrobial stewardship
Hand hygiene
AMS Network
Technical working group
ACSQHC Process: committees & modus operandi
• Expert groups – HAI Advisory Committee – AMS Advisory Committee
• Inter-Jurisdictional Committee – IJC will consider and provide advice to the Commission on the following: – The Commission’s programs, standards, guidelines and indicators and the
implementation of these; – The maintenance of effective working relationships with key stakeholders to facilitate
the work of the Commission; – Safety and quality issues regarding the Australian health care system; and – The process for collecting and reporting on national data on safety and quality issues.
• Liaison – Primary Care Committee
• The PCC is responsible for facilitating the engagement and uptake of Commission programs in the primary health care sector.
– Private Hospital Sector Committee • The PHSC is responsible for advising the Commission on key safety and quality initiatives from
the perspective of the private hospital sector.
ACSQHC Outcomes- in sequence
• Surveillance review and programs- SAB, CDI • National performance measures • NSQHS Standards • National IPC Guidelines- revision • Hand Hygiene Australia • Capacity building • AMS etc • CPE Guidelines
ACSQHC Tips for success
• Engagement of leaders – National – State and territory – Hospital – Professional organisations – Clinicians
• Provide “carrots” before the “stick” • National coordination • Recognise that “not one size fits all”
Other Australian national enablers • National communicable disease structures
– CDNA – PHLN – Laboratory : NPAAC, NATA, AGAR and NRL
• ACIPC – Credentialing – Journal – Research
• ASID & ASM • NHMRC research groups:
– N Graves group etc – AMS group etc
• ACHS and other accreditation assessors • Private Hospitals
Major Australian structural deficiencies
• Lack national Centre for Communicable Disease Control: • reliance on Expert panels for policy development • no centre for collation and epidemiological analysis of HAI
data • MRSA, VRE, CPE, C. difficile historically not regarded as
public health problems per se by some jurisdictions and the federal apparatus
• Aged care governance sits outside of ACSQHC’s province and the NSQHCS
McCall BJ et al. Aust Health Rev. 2013 Jun;37(3):300-3. The time has come for an Australian Centre for Disease Control.
Overview
1. Australian Healthcare System – Structure, Process and Outcomes; reactive versus proactive approaches to system repair - adding the ‘Safety 2’ ethos
2. The ACSQHC and other national programs & enablers
3. National Safety and Quality Healthcare Standards and Standard 3 – progress and challenges
Standard 7 Blood and Blood
Products
Standard 10 Preventing Falls and
Harm from Falls
2011 NSQHS Standards: mandated 2013
Standard 1 Governance for Safety and
Quality in Health Service Organisations
Standard 2 Partnering with Consumers
Standard 4 Medication Safety
Standard 3 Healthcare Associated Infections
Standard 8 Preventing and
Managing Pressure Injuries
Standard 9 Recognising and
Responding to Clinical Deterioration in Acute
Health Care
Standard 5 Patient Identification and Procedure Matching
Standard 6 Clinical Handover
NSQHC Standards
What has worked well • Comprehensive • Risk based approach • AMS inclusion • Strong acceptance and
uptake
Work still to do • Accreditation process:
variability in assessment stringency
• Governance and management structures insufficiently specified
• Continuous quality systems focus required
Standard 3: progress and challenges
1. Surveillance: performance assessment 2. National Hand Hygiene Program 3. Enhancing Standard Precautions: safer healthcare
environments 4. CAUTI prevention 5. National surveillance: critique of current programs 6. Resourcing and implementation of antimicrobial
stewardship across all healthcare settings
QI vs Performance assessment
• Solberg schema • Surveillance review 2008- rec national level
SAB, CDI surv
• National perf agreement • AIHW and NHPA politics
Outcomes: Hand Hygiene program
What has worked well • Strong acceptance and
uptake • Comprehensive • Validity studies
Work still to do • Nursing compliance
drives figures • Medical compliance
lagging or not measured well enough
• Cost benefit questions
Quote Graves et al study
Medicos and HH
• Medical college statement 2016 • Poor or absent accountability systems for
medicos • Poor medical update re training and poor
understanding
Accountability- Vanderbilt framework Australian pilot 2016
Talbot et al. Sustained Improvement in Hand Hygiene Adherence: Utilizing Shared Accountability and Financial Incentives. Infect Control Hosp Epidemiol 2013;34(11):1129-1136.
Standard 3: progress and challenges
1. Surveillance: performance assessment 2. National Hand Hygiene Program 3. Enhancing Standard Precautions: safer healthcare
environments 4. CAUTI prevention 5. National surveillance: critique of selected current
programs 6. Resourcing and implementation of antimicrobial
stewardship across all healthcare settings
Systems and safe environments
Structure Accountability & governance Accommodation and design Advanced environmental auditing methods Microfibre cloths, Vapour disinfection , UV Surfaces and cloths that have disinfectant properties
Process Environmental cleaning & disinfection– procedure control, staff training and competency Disinfection of reused patient equipment Audits of process compliance
HAUTI and CAUTI
Impact: Priorities: Improving use of urinary catheters – compliance with insertion guidelines and aseptic technique, nurse-led removal, outcome measure – HAUTI / CAUTI
Standard 3: challenges and priorities
1. Surveillance: performance assessment 2. National Hand Hygiene Program: medical
compliance and wider engagement with IPC and AMS processes
3. Enhancing Standard Precautions: safer healthcare environments
4. CAUTI prevention 5. National surveillance: critique of current programs 6. Resourcing and implementation of antimicrobial
stewardship across all healthcare settings
Staph. aureus BSI (SAB) Surveillance
http://www.safetyandquality.gov.au/our-work/healthcare-associated-infection/national-hai-surveillance-initiative/national-definition-and-caluculation-of-hai-staphylococcus-aureus-bacteraemia/
SAB surveillance What has worked well • Comprehensive coverage • Captures non-inpatient
events • High prominence –
publically reported, top level performance indicator; managers engaged++
Work still to do • Incident level reporting to
enable better analyses and data validation
• Private lab/hospital reports • Linkage of epidemiological
typing data • Public Health involvement –
MRSA issues in indigenous and RACF populations
• Many research level questions
Clostridium difficile infection (CDI) surveillance
• National CDI surveillance approach 2009
• Clostridium difficile workshop August 2010
• Clostridium difficile 027 Snapshot Study, October 2010
• Second national ribotyping survey November 2012
CDI surveillance definition
http://www.safetyandquality.gov.au/our-work/healthcare-associated-infection/national-hai-surveillance-initiative/national-definition-and-calculation-of-hospital-identified-clostridium-difficile-infection/
CDI surveillance
What has worked well • Surveillance definition –
few grey zones • Periodic snapshots with
subtyping • Has provided assurance
that epidemic CDI has not emerged in Australia
• High community rates
Work still to do • Test utilisation not
standardised • National reporting of HCA
CDI rates • Data completeness &
validation • Utility of CDI surveillance
for AMS/ IPC performance judgement?
ASID C. difficile guidelines update Internal Medicine 2016
Laboratory-based surveillance of Clostridium difficile circulating in Australia, September – November 2010. Cheng et al, Pathology 2016
C. difficile snapshot survey 2010
Increasing incidence of Clostridium difficile infection, Australia, 2011–2012. Slimings et al MJA 2014
ACSQHC CARAlert reporting system 2016
http://www.safetyandquality.gov.au/antimicrobial-use-and-resistance-in-australia/what-is-aura/national-alert-system-for-critical-antimicrobial-resistances-caralert/
CPE
• Recent extended CPE outbreak- Melbourne- galvanising involvement of public health at state and national level
• Likely notifiability • Re-energised review and revision of national
CPE guidelines
Standard 3: progress and challenges
1. Surveillance: performance assessment 2. National Hand Hygiene Program 3. Enhancing Standard Precautions: safer healthcare
environments 4. CAUTI prevention 5. National surveillance: critique of selected current
programs 6. Resourcing and implementation of antimicrobial
stewardship across all healthcare settings
– Morgyn Warner (Chair) – Celia Cooper (Prev Chair) – Helen van Gessel – David Looke – Margaret Duguid – Marilyn Cruickshank – David Kong – David Maxwell – John Turnidge – John Ferguson – Tara Anderson – Karin Thursky – Kirsty Buising
AMS Advisory Committee
Antimicrobial Stewardship Network
• Departmental representatives • Private Hospital sector • Paediatric component • Members from Antibiotic Stewardship Advisory Committee • AMS clinical standard – small number of quality statements
that will provide standard at the clinician/patient level
The Clinical Care Standard for AMS Tackling AMS at the patient level
Nine (9) statements describing best practice for managing a person who has, or is suspected of having a bacterial infection, regardless of setting.
• For patients: describes the care they can expect to receive throughout the patient journey.
• For clinicians: gives clear guidance about what they need to do.
• For health services: systems are in place to support all clinicians in providing the care that is expected.