VITAL SIGNS 2016 The State of Safety and Quality in Australian Health Care

1 Published by the Australian Commission on Safety and Quality in Health Care Postal Address: GPO Box 5480, Sydney NSW 2001 Phone: (02) 9126 3600 International +61 2 9126 3600 Email: [email protected] Website: www.safetyandquality.gov.au

ISSN 2002-7696 (print) ISSN 2206-9771 (online)

ABN 97 250 687 371

© Commonwealth of Australia 2016 All material and work produced by the Australian Commission on Safety and Quality in Health Care is protected by Commonwealth copyright. It may be reproduced in whole or in part for study or training purposes, subject to the inclusion of an acknowledgement of the source.

The Commission’s preference is that you attribute this publication (and any material sourced from it) using the following citation: Australian Commission on Safety and Quality in Health Care. Vital Signs 2016: The State of Safety and Quality in Australian Health Care. Sydney (Au), 2016.

An online version of this report can be accessed at www.safetyandquality.gov.au

Enquiries regarding the use of this publication are welcome and can be made by contacting the Commission’s Communications team via email at [email protected]

In some early printed copies of this document some figures were incorrectly numbered. The figure numbers have been adjusted in this version.

2 Contents Abbreviations...... 04 INTRODUCTION ...... 05 WILL MY CARE BE SAFE? ...... 06 What difference are the NSQHS Standards making to patient safety? ...... 07 Governing to ensure your care will be safe ...... 14 WILL I GET THE RIGHT CARE? ...... 17 Antimicrobial resistance and appropriate use of antibiotics ...... 19 Medicines, digital health and clinical safety: making sure technology supports clinicians to provide safe care to consumers ...... 26 WILL I BE A PARTNER IN MY CARE? ...... 28 What do Australians want and need during a hospital stay? ...... 29 Understanding health literacy ...... 33 CASE STUDIES ...... 37 Case Study 1: Australian Atlas of Healthcare Variation ...... 38 Case Study 2: Clinical quality registries ...... 46 Case study 3: Reducing unnecessary radiation exposure to children and young people from CT scans ...... 48 CONCLUSION ...... 53 REFERENCES ...... 55

3 Abbreviations

AMR Cone beam computed tomographyCT PBS Antimicrobial resistance Computed tomography

AMS EMM Antimicrobial stewardship Electronic medication management

ANZASM IT Australian and New Zealand Audit Information technology of Surgical Mortality MBS ANZDATA Medicare Benefits Schedule Australia and New Zealand Dialysis and Transplant Registry MRSA Methicillin-resistant Staphylococcus aureus AOANJRR Australian Orthopaedic Association NSQHS National Joint Replacement Registry National Safety and Quality Health Service

AURA OECD Antimicrobial Use and Resistance in Australia Organisation for Economic Co-operation and Development CBCT

4 Pharmaceutical Benefits SchemeRACS Royal Australasian College of Surgeons

SAC Safety assessment code

WHO World Health Organization

5 Introduction Welcome to this fourth annual edition of Vital 1. patient safety Signs, produced by the Australian Commission 2. partnering with patients, consumers and Australia performs very well in international on Safety and Quality in Health Care (the communities comparisons about healthcare outcomes. The Commission) to report on the state of safety and Australian population has high life expectancy, quality of health care in Australia in 2015–16. 3. quality, cost and value a relatively low rate of avoidable death and good survival rates from major cancer types and The Commission’s role is to lead and coordinate 4. supporting health professionals to provide cardiovascular disease. However, measuring the national improvements in the safety and quality care that is informed, supported and organised safety and quality of care can be challenging. of health care. The Commission works in to deliver safe and high-quality health care. While there is information about surgery, partnership with patients, carers, clinicians, emergency department attendances and visits to managers, policy makers and healthcare One of the Commission’s key functions is to general practitioners, there is less complete organisations to achieve a sustainable, safe and report on the state of safety and quality in the information about safety and quality. Vital high-quality health system. Australian health system. This is important Signs 2016 brings together information from a because it will inform how the health system is range of sources to provide a snapshot of safety Key functions of the Commission include performing, and how successful efforts are at and quality outcomes in a number of patient developing national safety and quality ensuring safety and quality health care for care areas. standards, developing clinical care standards to patients. This in turn assists the Commission improve the implementation of evidence-based and its partners to determine priorities for the Vital Signs 2016 also includes three case studies health care, coordinating work in specific areas future. that provide an in-depth analysis of safety in the to improve outcomes for patients, and providing This report, Vital Signs 2016, is structured context of healthcare variation, clinical quality information, publications and resources about around three important questions members of registries and reducing unnecessary radiation safety and quality. the public ask about their health care: exposure to children and young people. The case studies illustrate the type of work that is The Commission works in four priority areas: Will my care be safe? needed to properly understand if we are Will I get the right care? improving Will I be a partner in my care? the safety and quality of healthcare delivery.

6 Part One WILL MY CARE BE SAFE?

The Australian health system provides safe and high-quality care in the majority of cases. Unfortunately, some people do not always receive all the care that is recommended and adverse events occur. Doctors, nurses and everyone involved in the health care system work very hard to ensure that patients receive the best possible care and are protected from harm. But health care is a complex process that requires much planning and coordination – and sometimes things go wrong.

In order to minimise the risk that patients may be harmed, it is essential to ensure good processes are in place. Health services should have systems to ensure patient safety; likewise, people working in health services should be aware of those systems and use them properly.

This is one of the most important roles of the Commission – to ensure, through collaboration with its partners, that good systems are in place to protect patients. The Commission has worked with the Australian Government, state and territory governments, the private sector, clinical groups and patients, carers and consumers to develop rigorous national safety and quality standards, against which all hospitals and day procedure services in Australia must be assessed.

This section provides information on patient safety outcomes as a result of the implementation of the National Safety and Quality Health Service (NSQHS) Standards. What difference are the NSQHS Standards making to patient safety? The National Safety and Quality Health Service have led to increased priority being given to audits and other methods to evaluate (NSQHS) Standards were developed by the existing activities that aim to improve patient effectiveness of interventions. Commission in collaboration with states and safety. Examples are an increased focus on the territories, clinical experts, patients and carers. effective and appropriate use of antibiotics, The following sections provide examples of the The primary aims of the NSQHS Standards are better documentation of adverse drug reactions some of the improvements that have been to protect the public from harm and to improve and medication history, and an increase in the observed in the context of specific NSQHS the quality of health service provision. They number of hospitals reporting information Standards. provide a quality-assurance mechanism that nationally so that blood usage can be better tests whether relevant systems are in place to monitored. ensure expected standards of safety and quality Leadership for safety and quality are met. –NSQHS Standard 1 How do the NSQHS Standards The NSQHS Standards require that each health There are 10 NSQHS Standards, which cover make a difference? service organisation has an incident-monitoring high-prevalence adverse events, healthcare People working in health services in system that enables reporting of incidents of associated infections, medication safety, patient Australia report that the NSQHS Standards are patient harm and ‘near misses’, and which is identification and procedure matching, clinical making a difference by enhancing: used by health service leaders to improve care. handover, the prevention and management of • Incident monitoring helps to identify factors pressure injuries, the prevention of falls and leadership for safety and quality – emphasising the responsibility of local that are contributing to patient harm so they can responding to clinical deterioration. be addressed at a local level, and at a wider Importantly, these NSQHS Standards have hospital boards and executives for monitoring and taking action to improve system level if necessary. provided, for the first time, a nationally consistent statement about the standard of care safety and quality issues and encouraging a culture of safety Reporting incidents to reduce serious consumers can expect from their health service • harm organisations. clinical engagement – deepening the involvement of clinicians in designing and Most state and territory government health departments receive incident reports alerting The implementation of the NSQHS Standards in using safety and quality processes and tools them to issues or events that did, or could have, hospitals and day procedure centres has that are focused on safe patient care put patient safety at risk. In South Australia contributed to significant improvements in • effective systems – helping to ensure (SA), incident monitoring is integral to SA patient safety. The NSQHS Standards have targeted systems and processes are used and Health’s approach to patient safety. As part of a provided the impetus for new activities and they continually monitored through clinical patient safety culture, all health service staff process errors that may affect the delivery of reducing inappropriate use as well as improving report incidents routinely through the SA Safety safe and effective surgical care. patient outcomes.1,3 Learning System interface. Hospital managers, senior executives and SA Health can easily While originally used for review and learning The inclusion of antimicrobial stewardship in monitor how often incidents are occurring, their within the surgical profession, the ANZASM the NSQHS Standards has contributed to a near- severity, their causes and whether remedial process has started providing clinical trebling of the percentage of health service action has taken place. For staff, reporting governance reports for individual health organisations that reported having any AMS incidents helps them to learn and contribute to services to support quality, accreditation and program, to a point where they are now almost improving systems and processes. standards assessments, largely initiated in universal. response to the NSQHS Standards. Tracking and analysing incidents in this way brings benefits. While participation in safety reporting of incidents and near misses has Safe and appropriate prescribing increased in SA, the number of high harm of antimicrobials – NSQHS incidents of any kind has almost halved since Standard 3 2011 (see Figure 1). This suggests that greater Between 30% and 40% of hospitalised patients awareness and willingness to report incidents in Australia are prescribed antibiotics.1,2 has improved safety. However, not all of those prescriptions are of the appropriate type of antibiotic, dose or Integrating clinical and health duration. Resistance to antibiotics, as well as to other types of microbe-fighting medicines such service governance to as antifungal and antiviral drugs, is growing, so improve surgical safety it is critical that these medicines (called The Royal Australasian College of Surgeons antimicrobials) are used wisely and well. (RACS) has a system for reporting and investigating the death of any patient admitted Antimicrobial stewardship (AMS) programs under the care of a surgeon in hospitals optimise the use of antimicrobials through participating in the Australian and New Zealand activities such as prescribing audits, providing Audit of Surgical Mortality (ANZASM). The feedback to prescribers about how frequently ANZASM process is designed to highlight they prescribe these medicines compared to clinical events, adverse trends, and system and their peers, and prescribing restrictions. These types of activities have the double benefit of In 2015, 98% of respondents to a Commission immobility and extended bed rest. The NSQHS Auditing of timely assessment survey reported having an AMS program, Standards require health service organisations to A survey of private hospitals found that in compared with 36% before the NSQHS screen patients for their risk of pressure injuries 2010, before the NSQHS Standards were Standards (see Figure 2). and, for those at risk, to conduct a introduced, less than 30% of respondents comprehensive risk assessment and regular skin reported routinely auditing timeliness of assessments. pressure injury risk assessment. By 2014, these Pressure injuries – NSQHS A pressure injury management plan should be audits were reported as being routinely Standard 8 prepared and implemented if appropriate. performed by all respondent hospitals (see Pressure injuries are a known and largely Figure 3). preventable complication associated with SPOTLIGHT: Improved awareness of surgical adverse events–clinical governance and audits of surgical mortality The Australian and New Zealand Audit of surgery, and managers of safety and quality in Surgical Mortality (ANZASM) collects data The RACS has also produced a smartphone app late 2014 and early 2015. from surgical mortality audits conducted in each that allows ANZASM de-identified national state and territory. The aim of the audits is to case note reviews to be searched and cross- “The reports talk about your hospital and your identify system or process errors, which can referenced against items in the NSQHS peers as well as national data, and this gives an assurance to hospital executives.” – Ms Michele highlight priorities for improvement. Reports on Standards. McKinnon, Director, Safety and Quality, SA national audit results have been published since Current cases highlight clinical lessons related Health. 2009. to healthcare-associated infections, medication safety, pressure injuries, falls, clinical handover The reports are also delivered to state and The ANZASM has broad participation, and in and recognising clinical deterioration. territory health departments, allowing a 2014 included 97.5% of surgeons, 100% of jurisdictional view of patterns in surgical public hospitals and 97.5% of private hospitals. What prompted the change? mortality. The reports support action 1.2.1 of the What has changed since the NSQHS Standards: ‘Regular reports on safety “We had broad mortality data before this report, and quality indicators and other safety and but not this level of detail. introduction of the NSQHS We find it invaluable because now we can see what Standards? quality performance data are monitored by the we should target with quality improvement The Royal Australasian College of Surgeons executive level of governance.’ activities such as grand rounds and webinars. The reports are telling us a story about our care, and (RACS) has recently produced clinical this gives opportunities for quality improvement governance reports for individual hospitals, “The reports were very much influenced by the Standards – we were looking rather than blame.” – Ms Michele McKinnon. which include data on surgical mortality, for a way our data could be made more use of, and potentially preventable deficiencies of care there is no doubt that hospitals are pursuing ways identified by peer review, and comparisons with to satisfy the Standards. Giving them the state and national data for similar hospitals. information in a form that helps hospitals satisfy Standard 1 meant they were more likely to support it and make use of it.” – Professor Guy Maddern. “We were collecting all this data for educational purposes, and with the clinical governance reports How are the reports being used? we are giving the hospitals something they can use practically.” – Professor Guy Maddern, Chair, The first series of clinical governance reports ANZASM Steering Committee. was delivered to hospital CEOs, directors of Assessment and management patient) and Ryan’s Rule in Queensland (which In Queensland’s public hospitals, the percentage provides an avenue for patients, families and carers to seek help for a patient whose condition of patients assessed for pressure injury risk on is causing them concern). admission rose from 71% to 82% between 2011 and 2014 (see Figure 4). In Queensland, the proportion of public hospital patients that had a complete set of core Recognising and responding to observations recorded rose from 53% in 2011 to clinical deterioration in acute 81% in 2014. An appropriate chart was in place health care – NSQHS to record those observations for nearly 100% of Standard 9 patients in 2014 (see Figure 6). Before a patient goes into cardiac arrest, there are often changes in the person’s vital signs, All these results suggest that NSQHS Standard such as their blood pressure and respiratory rate. 9 has improved practices for recognising and Putting systems in place to recognise these signs responding to clinical deterioration in hospitals. of deterioration can help prevent cardiac arrest Over 80% of respondents to the 2015 and other serious outcomes. Commission survey agreed that the NSQHS Standard had had a positive impact. Surveys conducted by the Commission in 2010 and 2015 highlight improvements in the recognition and response systems reinforced Preventing falls and harm from and supported by NSQHS Standard 9. In 2015, falls – NSQHS Standard 10 substantially more hospitals had established Falls are a significant safety issue in health care, recognition and response systems, including and prevention of harm from falls is the primary early warning or track-and trigger tools (see Figure 5). Similarly, in 2010, only 18% of aim of NSQHS Standard 10. Falls prevention hospitals reported that their rapid-response has been a long-standing concern in hospitals, systems could be activated by patients, families as shown by the high rate of monitoring falls in and carers. By 2015, this had more than trebled private hospitals since 2010 (see Figure 7). to 56% (see Figure 5), supported in some jurisdictions by statewide programs such as the Patient and Family Activated Escalation (REACH) program in New South Wales (which empowers patients and families to escalate care if they are concerned about the condition of the

In South Australia, health service staff are from 1.34 to 0.88 per 10 000 occupied bed days In Queensland, the percentage of at-risk patients supported to report all the falls and near misses since the NSQHS Standards were introduced for whom falls-prevention plans were conducted that occur. While the reporting of falls incidents (see Figure 8). rose from 75% in 2011, before the NSQHS has increased with time, the rate of falls Standards were introduced, to 87% in 2014 (see involving serious patient harm has decreased Figure 9). What the Commission will do next

The Commission will continue to support The Commission is also planning to provide governance processes, and version 2 of the implementation of the NSQHS Standards by training for assessors from each accrediting NSQHS Standards will help embed partnerships developing a range of measures to support agency. It is the assessors’ job to examine the between patients and health care providers in safety and quality improvement. safety and quality systems that health service health care systems. organisations have in place. The training will Version 2 of the NSQHS Standards will To help health service organisations apply the ensure that each assessor has the same continue to emphasise systems to improve standards, they need guides that can explain and understanding of what is required when they patient safety in key areas such as the provide examples of ways that they can assess a health service. prevention of healthcare-associated infections introduce improvements. A series of Safety and and recognition and response to acute Quality Improvement guides are being prepared By 2019–20, health service organisations in a deterioration. They also include new areas that for hospitals, day procedure and other health range of sectors and settings will be will further improve safety for patients. In services. There are also fact sheets for implementing and being assessed against particular, a new NSQHS Standard about consumers and clinicians. version 2 of the NSQHS Standards. This can be comprehensive care has been added that expected to improve outcomes further for includes recognition and care of people with To help clinicians and managers access patients, with an associated reduction in adverse dementia and deliriums. information quickly and easily, the Commission events. Version 2 of the NSQHS Standards will will provide suitable resources, information and have an increased focus on integrated systems The Commission will provide resources, tools to help implement the NSQHS Standards. of governance to support best possible clinical training and support to help organisations meet Information sessions, training tools and outcomes, organisational safety culture and version 2 of the NSQHS Standards, and will communication resources will be made professional accountability, and a new national monitor the implementation and effectiveness of available to assist health service organisations model clinical governance framework is being version 2 of the NSQHS Standards. inform and engage their workforce in the use of developed. Health service organisations will be the NSQHS Standards. expected to partner with consumers in Governing to ensure your care will be safe “If you or a loved one is having a heart attack, which health service organisations, from boards standard and that they are equipped with your most pressing concerns probably include to frontline clinicians, account to patients and technology that allows clinicians to achieve the how quickly you can get to the hospital and the community for assuring the delivery of safe, best possible outcome for all patients under the quality of care you’ll receive. You’re effective, consistent and patient-centred health their care. probably not thinking about the hospital’s board room, even though quality of care for care, and for continuously improving the safety heart attacks and many other conditions may and quality of health services. Boards need to ensure that the staff employed be determined in large part by decisions made within the organisation are appropriately there.” trained, are sufficient in number, and possess – The New York Times, 15 February, 2015.4 Boards and the NSQHS the necessary skills to safely carry out any Boards of health service organisations, like the Standards procedures for which they have appropriate boards of all organisations, are responsible for To help boards carry out their function in credentials. Boards oversee the appointment and corporate governance. In a health service or relation to patient safety, the Commission performance of their chief executives, who, health facility, this is the system of practices developed a specific NSQHS Standard. together with members of the management and processes that control the operation of the ‘Standard 1: Governance for safety and quality teams, are responsible for the day-to-day service. Governance determines how health in health service organisations’ requires the management of their health service services are delivered, and it has a direct impact leaders of health service organisations to organisations and for the design and on the safety and quality of care. implement governance systems to set, monitor implementation of safety and quality systems. and improve the performance of their The board has ultimate responsibility for the organisations, and to communicate the The framework that delivers the assurance to governance of clinical care within the health importance of the patient experience and quality the board that the services the organisation service organisation. It is responsible for management systems to all members of their provides to patients are safe is known as the ensuring that effective safety and quality workforces. clinical governance framework. systems and robust organisation-wide governance practices are in place; that safety How does a board do this to Guide for boards and quality is monitored; and that the Feedback that the Commission has received organisation responds appropriately to safety ensure that your care will be from the states and territories and assessors and quality problems when they occur. Clinical safe? indicated that boards, and management, governance is an integrated component of Boards and management must ensure that the welcomed advice on how to establish a clinical corporate governance of health service facilities are appropriate for their intended governance system. In response, the organisations. It encompasses the systems by purposes, that they are built to an acceptable Commission published a guide for boards to use in exercising their governance responsibilities At a more detailed level, the guide advises the timely provision of supply items; the and accountabilities, specifically with reference board members about: cleanliness of the environment; and the to the implementation of the NSQHS Standards. standards of those who provide services to Broadly, the guide suggests that board • committees or groups to address issues in the organisation. members: detail • such as audit and risk, advice from • see themselves as institutional champions of consumers and feedback on clinical safety within their facilities processes and outcomes • familiarise themselves with the risks • comparing their facility’s performance inherent in the delivery of health care, both against that of other like facilities generally and within their particular service • policies, procedures and guides • ensure that management has in place • setting goals strategies to mitigate these risks • resourcing issues, including the number, • monitor the performance of the organisation training and qualifications of staff; the and receive feedback from a range of maintenance of buildings and equipment; sources, including consumers. • Part Two • WILL I GET THE RIGHT CARE?

• Ensuring that best-practice approaches are applied at the point of clinical care provision is an aspect of the Commission’s work – making sure that people get the right care. • • The Commission explores whether clinicians have the right information to assist in providing appropriate care to patients. It also examines if this knowledge is being applied, and if not, why not. • • This section of Vital Signs 2016 looks at the part of the Commission’s work that focuses on ensuring people get the right care in a range of clinical areas, including understanding resistance to and appropriate use of antibiotics in Australia, and supporting the safe use of online health resources. • • • Antimicrobial resistance and appropriate use of antibiotics • Antimicrobials are medicines designed to more complex and expensive, and in some programs provide valuable surveillance kill or slow the progress of infections, patients needing to stay in hospitals longer. data, a nationally coordinated approach was especially those caused by bacteria and Some people may die because they have needed so that policy makers could see a fungi. There are many kinds of infections that can no longer be treated. clearer picture. The AURA Surveillance antimicrobials; the most common are Many health organisations around the System, and the Commission’s work more antibiotics for treating bacterial infections. world, including the World Health broadly, supports a number of the objectives There are also antifungals, antivirals and Organization, recognise AMR as a major of the National Antimicrobial Resistance anti-parasitics. These antimicrobials are threat to public health affecting every Strategy 2015–19.6 essential to modern medicine. country.5 Australia is no exception. • • However, antimicrobials are losing their • • The Commission has been working with a effectiveness because many organisms that • The Commission’s Antimicrobial Use and range of partners to expand coverage by were once successfully treated by Resistance in Australia (AURA) increasing the number of hospitals and antimicrobials have become resistant to Surveillance System, funded by the laboratories that contribute data. It is also them. Some organisms have become Australian Government Department of working to enhance analysis and reporting completely resistant to many different Health, will help prevent and slow the to system users, and will establish new antimicrobials. This phenomenon is known progress of AMR by increasing systems where information gaps need to be as antimicrobial resistance (AMR). understanding of how antimicrobials are filled. • being used, and of patterns and trends in • The development of resistance is a natural AMR. o feature of bacterial evolution. However, as a • community, we have been contributing to AMR by using antimicrobials too often, o What is Australia when they are not needed, or for the wrong doing to fight AMR? types of infection. Resistance is spreading; once thought to be a problem only in • In Australia, laboratories and surveillance hospitals, it is now found just as often in the programs detect and monitor AMR. community. Hospitals, residential aged-care facilities • and some parts of the community use audit • AMR is a significant healthcare issue that tools and systems to monitor antimicrobial can result in medical treatments becoming use and its appropriateness. While these o AURA Surveillance o The First Australian • These resistances have a major impact on seriously ill patients in hospital and require System program Report on significant efforts and investment of partners Antimicrobial Use and resources by hospitals to control their • Australian Group on Antimicrobial Resistance in Human spread. Resistance • Health • There are variations between the states and • National Centre for Antimicrobial • The Commission has released the First territories for specific types of resistant Stewardship: National Antimicrobial Australian Report on Antimicrobial Use and organisms. For example, in 2014, the overall Prescribing Survey Resistance in Human Health (AURA 2016) rate of resistance for methicillin-resistant • South Australia Health National using data from the AURA Surveillance Staphylococcus aureus (MRSA) ranged a1 Antimicrobial Utilisation Surveillance System. from 3.8% in Tasmania to 42.2% in the Program • Northern Territory (see Figure 12). • AURA 2016 focuses on resistance rates for • • National Neisseria Network organisms that have been identified as • National Notifiable Diseases Surveillance priority organisms in Australia. If these o What does AURA 2016 System organisms develop high resistance to the ‘last-line’ antimicrobials, it is likely that say about • NPS MedicineWise MedicineInsight there will be significant increases in antimicrobial use in Program morbidity and mortality rates. Australia? • Australian Government Pharmaceutical • • In 2014, 46% of the Australian population Benefits Scheme and Repatriation • Of the priority organisms, one of the were prescribed antimicrobials in the Pharmaceutical Benefits Scheme Enterococcus species is most resistant to community, which is high by international antimicrobials. Enterococcus species are • Queensland Health OrgTRx system standards (see Figure 13). opportunistic pathogens that cause a range • • Sullivan Nicolaides Pathology, Brisbane of infections in patients whose immune • In hospitals, 23% of antimicrobial system is already compromised due to • Mater Misericordiae Health Services, prescriptions were deemed to be in surgery or invasive devices. Brisbane appropriate, most commonly because the • antimicrobial was not indicated in the • States and territories. • The proportion of Enterococcus faecium patient medical chart, the spectrum was too strains that are resistant to the antimicrobial broad, the duration of treatment was vancomycin is almost 50% – one of the incorrect, or the dose or frequency was highest rates in the world. Resistance to incorrect. ampicillin was even higher in this species, at • about 90% (see Figure 11). • In residential aged-care facilities in 2014, a • pilot study found that 11.3% of residents were on antimicrobial treatment, but only 1a All data is from 2014 • 4.5% of residents had suspected or confirmed infections. Further work will be o Priority organisms for undertaken in conjunction with stakeholders to better understand this issue and promote AURA Surveillance more appropriate prescribing in these System facilities. • Enterobacteriaceae o CARAlert • Enterococcus species • Eight types of resistance to antimicrobials, • Mycobacterium tuberculosis which are currently uncommon, but have the • Neisseria gonorrhoeae potential to increase and become a major health care problem, are being monitored • Neisseria meningitidis through the AURA • Surveillance System using CARAlert – the • Salmonella species national alert system for critical • Shigella species antimicrobial resistances. • • Staphylococcus aureus • CARAlert collects data from a network of • Streptococcus pneumonia. laboratories around Australia and sends alerts on confirmed critical AMR to health • departments for action, where necessary. CARAlert also produces regular reports to inform states and territories of further detail on these critical resistances. • o What the Commission to better inform strategies and programs to appropriateness and AMR. The information will do next prevent and contain AMR. can be used to inform and enhance their • infection prevention and control programs • The Commission will continue to improve • While the availability and accuracy of data and antimicrobial stewardship programs. the AURA Surveillance System by is critical, these data must lead to action. For Governments and healthcare organisations expanding the number of hospitals and example, hospitals and healthcare facilities can also use the information to inform pathology laboratories contributing data, can use the reporting from the AURA policy and influence change. The and the number of organisms under Surveillance System to monitor trends in Commission will use the AURA program to surveillance. This will provide data and their local antimicrobial use, inform and support these activities. information to clinicians and policy makers • Medicines, digital health and clinical safety: making sure technology supports clinicians to provide safe care to consumers • Medicines are the most common treatment • New technologies offer a promising avenue accompanied by measures that ensure they used in health care and contribute to for improving medication safety. The role of are safe and are used in a way that protects significant improvements in health when digital health in this regard will be patients. Steps being taken by the used appropriately. fundamental. • Commission to contribute to the safe use of • However, medicine use can also be • digital health systems are discussed below. associated with harm, and the high use of • There are clear benefits to implementing medicines means they are associated with digital health systems that could reduce o Safety issues with the more errors and adverse events than any errors. For example, an electronic use of digital health other aspect of health care. medication management (EMM) system can • Clinical safety needs to be built into the • While rates of serious harm are low, errors help reduce the frequency of medication- planning and development phases of any do affect health outcomes for people and associated hospital admissions by: system rollout if risks to patients are to be increase healthcare costs. For example, • minimised. For example, hardware, software medication related hospital admissions in • improving the legibility of medication and the networks underpinning digital health 8 Australia account for about 2% to 3% of all information systems must be robust and must recover 7 admissions. • providing warnings to prescribers regarding quickly from breakdowns and failures with • adverse reactions with existing conditions or minimal impact. • The prevalence of medication errors is of other medications the patient is taking. • particular concern because most of these • • Digital health systems also need to be usable errors are preventable. • In addition, the increasing utilisation of the by and intuitive for clinicians. For example, • My Health Record system is also likely to a poorly designed interface might not • In order to improve the safety and quality of help reduce medication errors and improve display important clinical information in a medicine use, we need to know how adverse health outcomes. manner that a clinician would expect, medication events occur and how they can • leading to an incorrect interpretation of be prevented. This is true both at the level of • However, the rapid uptake and use of digital patient data. individual practice and within systems for health systems can also cause new risks to • 9 managing medicines. clinical safety. The risks and the benefits of • Once digital health systems are in place and • digital health must be balanced. The in use, ongoing, proactive monitoring to introduction of these systems needs to be identify clinical safety issues that may arise • advising on how to embed more clinical published national guidelines for safe on- is essential. useability-testing into new releases of the screen presentation of medicines. These • system. guidelines aim to increase the ability of • Also, there are standard issues that affect all clinicians to clearly and safely interpret this systems. These include system failures • The Commission also provides clinical data when using clinical information (often measured as down time), lack of safety advice for consideration when new systems in routine patient care. system backup and integration problems My Health Record system functionality is • between connected systems. For example, a being planned and developed. • Similarly, the Commission has also hospital patient administration system and • developed guidelines for the safe on-screen its electronic medical record system might • When potential clinical safety issues are presentation of discharge summaries. These not be set up to share information for the identified involving the My Health Record guidelines identify what information is same patient. system, these are escalated to the critical for readers, and how to present this • Commission by the system operator. The information in a clear and precise manner Commission reviews the issues with expert for appropriate handover of care. o My Health Record users, and if necessary, conducts a formal • investigation, to identify factors contributing system to these issues, and to recommend ways to o What the Commission • The Commission has been appointed by the improve the system. Australian Digital Health Agency to provide • will do next a clinical safety oversight program for the • The Commission has developed a clinical • The Commission will continue its My My Health Record. The Commission incident management framework for the My Health Record clinical safety program and supports efforts by the Australian Digital Health Record system, to support a more will support the new Australian Digital Health Agency, as the system operator, to structured and evidence-based approach to Health Agency as the system operator. The enhance the clinical safety of the My Health clinical incident management. The Commission will also continue its broader Record system by undertaking clinical framework puts in place a process to rapidly digital health safety functions, and has safety reviews. Recent review topics have identify, escalate and investigate clinical commenced: included: incidents that arise. • • • • a literature review on best practice • examining the impact on clinical workflows • The Commission has also reviewed the management of digital health safety as a result of emergency department processes in place to assess clinical software incidents to understand what is happening clinicians using the My Health Record systems for conformity with clinical safety internationally system requirements before those systems can • consultation and a literature review to connect to the My Health Record system. inform the development and publication of • identifying potential improvements to the • the third edition of the guide to safe My Health Record system for safer • To support the My Health Record system implementation of hospital EMM systems decision-making and to promote broader and to drive the broader national digital • development of a self-assessment tool for uptake by clinicians health safety agenda, the Commission has hospitals where EMM is implemented. • Part Two WILL I BE A PARTNER IN MY CARE?

The Commission supports the right of people to be partners in their health care. It is a priority for the Commission to have a health system in which patients, consumers and members of the community participate with health professionals as partners in all aspects of health care.

Bringing together the two perspectives of consumers and clinicians to form this partnership can be challenging. Many clinicians are very busy and may question how much time they will need, while consumers may not understand how they can effectively contribute to their own health care.

The Commission has provided tools, strategies and approaches to support all involved in healthcare provision to form effective partnerships. It is working to make the health system easier to understand for consumers, so they can be in a better position to form a true partnership.

This section looks at some of the Commission’s research around the patient experience, and looks at health literacy and how it affects partnerships, as well as good examples of effective partnerships. What do Australians want and need during a hospital stay? “When someone acknowledges us, or listens to a mistake had been made, this did not “I feel comforted by the fact that somebody is us, or comforts us, or explains things to us, it’s necessarily leave the patient with a poor telling me this is what’s going on. This is what so much better … we just feel better because experience. Honest and clear explanations and we’re doing. You might have to be in for a little bit longer. I just find that that sort of someone has cared for us” – Consumer, WA. disclosures could make mistakes a less negative feeling – like you’re a part of your care – is In an Australia-first study conducted in late experience. really important to me and – feeling like 2015, the Commission asked 86 consumers and you’re a human being.” – Consumer, ACT. carers what a good experience of hospital meant to them. These people came from all over The 20 dimensions of a positive Australia, from diverse backgrounds and patient experience different generations, and had varied Many of the dimensions of a positive experiences of health care. Over the course of experience related to how a person was treated. 17 in-depth group discussions, the Commission Consumers did not only see their ‘treatment’ in found that people very clearly knew what they terms of what medication they were given or the wanted and needed when they used the health type of surgery performed, but also in terms of system. the attitudes and behaviours of health professionals displayed during interpersonal Some needs and preferences appeared to be encounters. simple or obvious. People wanted to be treated like a person – not like an object, a collection of These 20 key dimensions can be grouped into vital signs, a disease, or a body part. They four types of interaction that a person has with a wanted their concerns to be taken seriously, not health service (see Figure 14). The dimensions dismissed. They wanted to be told what was most often mentioned by the study participants happening, not be kept in the dark. They wanted were aspects of interpersonal encounters with their expertise about their own body and their health professionals and other staff members own illness to be respected. They wanted to be (including being heard and being informed), and free from harm and to feel safe and secure. the quality and safety of clinical treatment and procedures (including concerns about mistakes, Importantly, the Commission learned that even infection control practices, and staff skill in when a health professional or service did not basic procedures such as cannula insertion). meet a person’s needs or expectations, or when “I was there actually to have an operation on assessed 39 Australian studies and found the Innovative examples of patient my left eye. The form said right eye. So I following seven issues to be the most experience improvement thought okay. So I said look, I think there’s an commonly occurring influences on the quality error here. There is an error here. It’s my left Here are three examples of innovative of experience: eye, not my right eye. Oh okay, we’ll just approaches to the collection and use of patient check the doctor’s letter. So she went to the experience information. doctor’s letter and it definitely said left eye.” – • reciprocal communication and information- Consumer, SA. sharing NSW Agency for Clinical Innovation • interpersonal skills and professionalism of Many people have chronic or complex Consumers said that their experiences were staff conditions that mean they have to see many influenced by care design and delivery – the • the care environment different health professionals and services. Most organisation of care and the way it was • correct treatment and physical outcomes approaches to assessing experiences are limited delivered to them (including coordination of • emotional support to one episode of care; for example, patient care), and also by their impressions of the • comfort, pain and clinical care surveys most commonly ask about one stay in priorities and administrative processes of the • discharge planning and process. hospital more generally (including hospital, one day procedure or one attendance at an outpatient clinic. They therefore do not responsiveness to complaints). That review and the Commission’s study, capture a patient’s entire experience of supported by previous research, offer a transition between services. These transitions “Throughout the whole thing, everyone looked at comprehensive articulation of what Australian their little bit of the puzzle, whether it’s been are especially important for the increasing patients want and need from their healthcare surgery or chemo or physio or whatever; very few number of people with chronic conditions. In stay. The Commission’s findings add to other of them have looked at the whole person to say, contrast, the Agency for Clinical Innovation in well this girl is really struggling right now.” – studies by showing that while patients are most NSW is piloting interventions to improve the Consumer, NSW. interested in the interpersonal and clinical integration of care across primary care and aspects of their stay, the organisation of their “I had an amazing response [to my complaint], hospital sectors. This means different care and their impression of a hospital’s which I was actually thrilled about. They’re organisations are working together to ensure actually having me back to talk to the ward staff priorities are also vital to a satisfactory patient that a person’s experience of their care is like a next in a couple of weeks’ time about what experience. happened.” – Consumer, NSW. seamless pathway, rather than a disjointed series of visits to services, which do not talk to one The 20 dimensions of a positive patient another. To assess whether this is working or experience identified in the study reinforce the not, a patient-centred evaluation is being findings of other research with Australian conducted across 10 sites. This is innovative in patients. A recent review of factors influencing trying to measure patients’ experiences between a positive or negative experience in hospital as well as within services. It is also innovative in asking patients about their health outcomes accompanied by audio in the appropriate after treatment as well as their experiences of language. What the Commission will do care. next The Commission will continue to support services in all states and territories and across SA Health public and private sectors to improve the quality Patients’ experiences are traditionally assessed of their patients’ experiences. In particular, the using telephone interviewing or written Commission will build a set of questions for questionnaires. This means that many people Eye-tech Day Surgeries national use. These questions will enable cannot have their say because of language One day hospital in Queensland, operated by services and governments to access patient barriers, cognitive impairment or literacy skills. Eyetech Day Surgeries, routinely invites a perspectives in a consistent way all over the In South Australia, an innovative pilot program consumer to tell their story to healthcare country. The question set will be tailored to the is testing a novel way of asking vulnerable and professionals at the beginning of staff meetings. concerns of Australian consumers, health disadvantaged populations about their The staff then discuss what changes, if any, the professionals and policy makers. It will be healthcare experiences. The program is using hospital could make to improve their service. A capable of producing information that will drive tablet computers and trained interviewers to ask record is kept of consumers’ suggestions along quality and safety improvement at ward, people what they think. The questions are asked with actions taken by staff in response. This organisation and regional levels. on the tablet using pictorial methods such as a helps ensure continuous quality improvement cartoon character called Fabio the Frog, and staff development. Understanding health literacy A person’s level of health literacy reflects the The health literacy environment is the There are different types of partnerships within degree to which they understand information combination of infrastructure, policies, the health system. At the level of the individual, about health and health care, how they apply processes, materials, people and relationships partnerships relate to the interaction between that information to their lives and how they use within the health system that make it easier or health professionals and patients when care is it to make decisions and act on them. more difficult for consumers to navigate, delivered. Such partnerships involve providing About 60% of adult Australians have low health understand and use. The complexity of the respectful care, sharing information and literacy.14 The combination of low levels of health literacy environment influences how supporting patients, carers and families to plan health literacy in the population and the consumers make decisions and take action care and make decisions about their own care. demands from an increasingly complex health about health and health care. system can have a significant impact on Partnerships also operate at the service level, individual health outcomes and the safety and Addressing health literacy has the potential not where patients, carers, families and consumers quality of health care. only to improve the safety and quality of health participate in governance, policy and planning care, but also to increase equity and to reduce in areas such as patient safety, service and There are two components to health literacy: health disparities. facility design, evaluation and quality individual health literacy, and the health literacy improvement. environment. Health literacy is important for A focus on health literacy is one way of Individual health literacy can be understood as effective partnerships ensuring that patients, carers, families and the skills and knowledge of a person, and their Partnerships at all levels of the health system consumers can participate fully in partnerships capacity and motivation to access, understand, are needed to reach mutually beneficial at all levels of health care provision. appraise and use information to make effective outcomes. Care that is based on partnerships decisions about their health and health care. provides many benefits for patients, consumers, Individual health literacy is dynamic and can clinicians, health service organisations and the A national approach to health change depending on issues such as stress, health system. For partnerships to work literacy illness and life course. It is influenced by the effectively, everyone involved in the The Commission’s National Statement on environment and by a person’s upbringing. In partnership needs to be able to give and to Health Literacy, endorsed by all Australian some cases, the likelihood of lower individual receive, interpret and act on information. Health health ministers in 2014, represents a health literacy is increased where disadvantage literacy is fundamental to these relationships coordinated national approach to addressing and vulnerabilities intersect. and processes. health literacy. It identifies three types of action A focus on the health literacy Taking steps to make the health literacy needed for this to occur (see Figure 15): environment more friendly to consumers, and to environment reduce unnecessary demands on people who • embedding health literacy into systems – A range of tools is available to measure interact with the health system, should improve this involves developing and implementing individual health literacy levels. However, these the experiences of the health system for systems and policies at an organisational tools often focus on different elements and there patients, carers and their families. and societal level that support action to is no one tool that is universally accepted. It address health literacy may also not be practical or useful to try to • ensuring effective communication – this assess the health literacy of every person within How can the health literacy involves providing print, electronic or other the timeframe of a consultation. environment be influenced? communication that is appropriate for the Several tools now exist, and others are being The Commission supports a ‘universal needs of consumers, and also involves developed, that can be used to assess the health precautions’ approach to health literacy that supporting effective partnerships, literacy environment of individual healthcare works on the assumption that it is not possible communication and interpersonal organisations. relationships between consumers, healthcare to know a person’s level of individual health literacy without performing an assessment, providers, managers, administrative staff There are several core components of the health which may not always be practical or desirable and others literacy environment that can be reviewed and during an episode of care. It therefore assumes • integrating health literacy into education – improved to make it easier for people to that there will be barriers to understanding and this involves education of consumers and navigate, understand and use health services. that there is a need to reduce the complexity of healthcare providers. These include: information and services that are provided. While recognising that everyone has a part to • navigation and way-finding, such as play in addressing health literacy, people and telephone systems, signage, maps and organisations working in the health system have reception areas a special responsibility to ensure that the health • print communication, including writing style literacy environment makes it as easy as and use of appropriate illustrations • oral possible for patients, carers, families and communication, such as staff offering to consumers to access, understand and act on help with filling in forms and healthcare health-related information. This includes providers checking that they have explained communicating with consumers in a way that information in a way that consumers supports safer care and better health outcomes. understand • technology, such as the availability and health literacy: Taking action to improve safety functionality of televisions, telephones, and quality with a focus on: What the Commission will do computers, web pages, apps, online tools next and kiosks • policies and procedures to support health The need to provide care that is based on • policies and protocols, such as development literacy partnerships and aligns with the expressed of consumer-focused publications, staff • navigation and way-finding to support preferences and needs of consumers underpins orientation and ongoing training. health literacy all of the NSQHS Standards. These standards • • supporting the healthcare team to support are currently being revised, and version 2 will Investing in understanding a consumer’s health literacy place greater emphasis on partnerships with experience of these components is a useful • developing, assessing and improving consumers. method to highlight where improvements may consumer information. be needed. Strategies may target different points Improving health literacy ensures that of the consumer journey: before they enter the The Commission has also been active in consumers can fully participate in partnerships health service organisation, when they arrive, continuing to raise awareness about health with healthcare providers, and that the health and during and after their visit. literacy, particularly through channels relevant system and healthcare organisations are oriented to health professionals such as conferences, to support such partnerships. Version 2 will workshops and professional education events. ensure that Australian health service Assisting health service This has involved the use and distribution of a organisations communicate with consumers in a organisations to improve suite of health literacy infographics and way that supports effective partnerships, and their health literacy resources for clinicians and health service will work to embed health literacy into the environment managers. organisation’s systems. To support local action, the Commission A fact sheet was also published to explain how developed a series of fact sheets to help health The Commission will also develop a scoping actions in the NSQHS Standards relate to health service organisations improve their health paper to consider approaches that the literacy and some of the health literacy literacy environment. These resources align Commission could take to foster improvements strategies that could be considered as health with the actions in the National statement on in the quality of health information for service organisations put systems in place to consumers in Australia, including looking at meet the NSQHS Standards. options for national guidance or standards. It will be an invaluable tool in years to come for policymakers, planners and health care Part Four managers to note the variation, to see if there are good reasons for it to exist, to think about the consequences for consumers of that variation and, if appropriate, to address it. Used wisely, the atlas could be an important tool in CASE efforts to address inequalities in health care. This section contains a case study relating to the landmark atlas work.

There are two other case studies: one of which STUDIE addresses the evidence of the benefits of clinical quality registries, while the other focuses on efforts to protect children and adolescents from the potentially harmful effects of unnecessary S computed tomography (CT) scans.

Three case studies are included that provide an insight into the state of safety and quality in the Australian health care system, including some work that the Commission has been leading.

A highlight of the Commission’s work during the past year has been the development and launch of the first edition of the Australian Atlas of Healthcare Variation. This atlas is the result of years of work gathering and analysing data. It presents clear evidence of the variation in health care around Australia. The for been used use across evidence care that is Commissi performan to explore the in not in Case Study 1: on has ce and variation country, Australia accordance Australian Atlas of collaborate statistical across and across and with d with the purposes different many internation evidence- Healthcare Australian, at both healthcare areas of ally based state and state16 settings. In health suggests practice. Variation territory and addition, care. Some that much This Modern areas and care. But governmen national this is the of this of the unwarrante 17, 18, medicine among where ts, levels. first observed variation d variation 19 is individual variation is specialist This is Australian variation documente may mean characteris clinicians. unwarrante medical the first atlas in will be d in the that some ed by an Understan d, it colleges, time that which warranted atlas is people are increasing ding this signals clinicians data from healthcare and likely to be missing expectatio variation is that people and the variation associated unwarrante out on n that critical to are not consumer Medicare across the with need d.20 It health care people will improving getting representat Benefits country related may that could receive the quality, appropriat ives to Schedule has been factors reflect have care that is value and e care. develop (MBS), presented such as differences helped evidence- appropriat Examining the Pharmaceu alongside underlying in them– based. eness of variation is Australian tical national differences clinicians’ such as Despite health an Atlas of Benefits recommen in the practices, cataract this care. Some important Healthcare Scheme dations for health of in the surgery – expectatio variation is first step in Variation. (PBS) and action. specific organisatio while n, the desirable identifying For many Admitted population n of health others are safety and and and years, Patient We now s, or care, and having quality of warranted: addressing Australia Care have a personal in people’s interventio health care it reflects unwarrante has been National clear preference access to ns that are varies, differences d reporting Minimum picture of s. services. It unlikely to both in people’s variation. on aspects Data Set substantial may also be of across need for of (APC variation However, reflect benefit. geographic health healthcare NMDS) in the weight poor- Overuse of variation have all healthcare of quality some interventio identifies a poorer access to in private examining the health is ns should ns, such as number of health and affordable, settings. this issue of unacceptab be. The unnecessar geographic thus a accessible These are further by Aboriginal le. 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Rates higher col her exp cov vel and for or a family were participati ono risk lain er lon people history of markedly on in sco ) the • loc g higher in metropolit py • rate who have bowel hig al dist local areas an areas.11 in s of a moderate cancer. in and Potential peo peo her ava anc or high around reasons for ple ple col ilab es risk of Almost capital the wh cho ono ilit ma bowel 600 000 cities and variation o osi sco y y MBS- disease for were lower include do ng py of be funded other in remote differences not to rate col a fibre-optic areas. In in: nee hav reasons.10 s in ono bar colonosco major • clin d it e These pies were cities, rates ical (no fae hig sco rier other performed were dec pos cal her py . reasons in lowest in isio itiv occ soc ser The include Australia areas of n- e ult ioe vic Commissi in 2013– symptoms low ma fae blo con es on is 14.b2 Very such as socioecono kin cal od om in working large mic status g occ test bleeding ic with variations and and ult scr rur from the were seen increased clin blo een are al partner bowel, in in areas of icia od ing as, and organisatio blood in colonosco higher ns’ test . wh re ns to make the stool, py rates socioecono adh , no ere mo sure the unexplaine 2b Data for mic status. • lev vat mo te people publicly- Participati d els e re loc who would funded on in the hospital of hea abdominal National peo atio benefit services are pri lth pain, a excluded. ple ns, most from colonosco Variati through a cause In 2012– with the cov tor1 y py do not small harm and 13, there lowest er 4 suc miss out. on incision, does not were more rate. and • risk h acc fact as Increasing in and help to than 33 ess ors phy awareness rat instrument manage 000 knee Possible to for siot of faecal es s can be knee arthroscop reasons for pri kne her occult inserted osteoarthri y the vat e apy blood of through tis.12,13 admissions variation e pro for testing, kne other Exercise to hospital. include hos ble peo and incisions therapy Hospital differences pita ms, ple ls – incl in availability e to operate has been admission in: abo udi re of art on the shown to rates for • clin ut ng mo colonosco hro knee. be more knee icia 80 obe te py services effective at arthroscop ns % sity loc not outside sco Many reducing y tended to of and atio foll city areas, py trials have osteoarthri be higher ad occ ns. owi mis upa are Knee shown that tic knee in inner ng sio tio The important arthroscop arthroscop pain than and outer evi ns nal Commissi parts of y is a y for knee regional den for inj on this work. surgical degenerati arthroscop areas than ce kne uri 12 bas established procedure ve knee y. in major e es ed the Knee for disease Despite cities. 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To l and to Australia. d action nic • co evi the Co These and He m den Me m target alth mis ce dic The 2015 cooperatio clinician, Me sio for are mis atlas n between consumer dia, nin out Be sio included many and whi g pati nef n possible groups. system- ch res ent its will reasons for The level aire ear ort Sch the Commissi d ch hop edu do strategies, variations on has on to aed le nex and AB ass ic Re reported, worked include: C ess tria vie t and with a • co 24 the ge w Identifying recommen range of m in ava clin Tas inappropri dations for partners, mis Feb ilab ics kfo ate action. 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The study practitione use the outcomes, quality. A 2012 looked at rs to informatio and internation 13 clinical engage in Case Study 2: n they analyse Clinical al study quality continuous Clinical quality collect to and feed quality found that registries learning identify back registries if clinical set up in and to registries benchmark informatio are a quality five identify s – for n into fundament registries countries: and share Another and report By finding example, clinical al part of provided Australia, best aspect of health- out which what rate practice the system informatio Denmark, clinical the related patients of and of n about the Sweden, practices”. Commissi informatio have better readmissio decision- continuous outcomes the UK For on’s work n. They outcomes, n might be making. improvem of health and the example, that has work by clinicians, considered Clinical ent in care US. The the study great tracking researchers normal quality health care practice to study estimated potential the health , policy and registries, safety and health concluded that the to bring outcomes makers potentially which are quality. practitione that well United improvem of patients and the abnormal typically rs and the managed States ents in with the public can after a set up and There is public, registries would safety and same tell what specific operated strong health “enable have quality in diagnosis type of type of by relevant evidence outcomes the Potential avoided Australian (such as treatments procedure. clinical already improved, to Use $US2 health care hip work most Outcome Data By groups, internation and in to Improve billion of relates to fracture), effectively tracking provide ally to many Health Care’s an clinical or who and Value. the informatio show that instances Larsson, S., expected quality undergo improve progress of n for the clinical money Lawyer P., $US24 registries. the same treatments Garellick G., patients, investigati quality was saved. Lindahl B., billion in Clinical type of and clinical on and registries C3 Lundström M. total costs quality procedure processes. Health Aff quality manageme can bring January 2012 for hip registries (such as 3C Use Of 13 registries nt of poor marked 31:220-227. replaceme collect, prostate The Disease http://content. are able to performan improvem Registries in 5 healthaffairs.o nt analyse surgery). clinical Countries rg/content/31/ identify ce to ents, and demonstrates 1/220.abstract surgeries in 2015, if Historicall those estimated had on the value varies health care clinical it had a y, there benefits in $618 their of from $2 to delivery. quality clinical has been this million clinical healthcare as much as Benefits registry quality relatively country. between practices. delivery at $7. include successful. registry for little work The 1999 and It has also relatively greater The these in Commissi 2014. looked at low cost. 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