Lessons for the Australian healthcare system from the Berwick report
Lesley Russell A B and Paresh Dawda A
+ Author Affiliations
- Author Affiliations
A Australian Primary Health Care Research Institute, Australian National University, Building 63, Cnr Mills and Eggleston Roads, Acton, ACT 0200, Australia.
B Corresponding author. Email: lesley.russell@anu.edu.au
Australian Health Review 38(1) 106-108 https://doi.org/10.1071/AH13185
Submitted: 4 October 2013 Accepted: 4 November 2013 Published: 13 December 2013
Abstract
There are common key recommendations in the raft of recent reports from inquiries into hospital quality and safety issues, both in Australia and in the United Kingdom. Prime among these is that governments, bureaucrats, clinicians and administrators must work together to place the quality and safety of patient care above all other aims in the healthcare system. Performance targets and enforcement, although needed, are not the route to improvement; what is required is a change in culture to drive a system of care that is open to learning, capable of identifying and admitting its problems and acting to correct them, and where the patient’s voice is always heard.
References
[1] Douglas N, Robinson J, Fahy K. Reports to the inquiry into obstetric and gynaecological services at King Edward Memorial Hospital 1990−2000. 2001. Available at http://www.kemh.health.wa.gov.au/general/KEMH_Inquiry/reports.htm [verified November 2013][2] Community and Health Services Complaints Commissioner of the ACT. A final report of the investigation into adverse patient outcomes of neurosurgical services provided by the Canberra Hospital. Canberra: ACT Government; 2003. Available at http://health.act.gov.au/publications/reports/neurosurgery-service-final-report [verified September 2013]
[3] Walker B. Final report of the Special Commission of Inquiry into Campbelltown and Camden Hospitals. Sydney: New South Wales Attorney General’s Department; 2004.
[4] Davies G. Queensland public hospitals commission of inquiry report. Brisbane: Health Quality and Complaints Commission; 2005.
[5] Joint Select Committee on the Royal North Shore Hospital. Report on inquiry into the Royal North Shore Hospital. Sydney: New South Wales Parliament; 2007. Available at http://www.parliament.nsw.gov.au/prod/parlment/committee.nsf/0/2067fbc90d0e6eb4ca2573b700008fbb/$FILE/071220%20Final%20Report.pdf [verified September 2013]
[6] Garling P. Final report of the special commission of inquiry into acute care services in NSW public hospitals. Sydney: NSW Department of Attorney General and Justice; 2008. Available at http://www.lawlink.nsw.gov.au/Lawlink/Corporate/ll_corporate.nsf/pages/attorney_generals_department_acsinquiry [verified September 2013]
[7] The Bristol Royal Infirmary Inquiry. Learning from Bristol: the report of the public inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984–1995. CM 5207. London: Stationery Office; 2001. Available at http://webarchive.nationalarchives.gov.uk/20090811143745/http://www.bristol-inquiry.org.uk [verified September 2013]
[8] The Mid Staffordshire NHS Foundation Trust. Public inquiry chaired by Robert Francis. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. 3 vols. London: Stationery Office; 2013. Available at http://www.midstaffspublicinquiry.com/report [verified September 2013]
[9] Keogh B. Review into the quality of care and treatment provided by 14 hospital trusts in England: overview report. London: National Health Service; 2013. Available at: http://www.nhs.uk/NHSEngland/bruce-keogh-review/Documents/outcomes/keogh-review-final-report.pdf [verified September 2013].
[10] Berwick D. A promise to learn – a commitment to act. Improving the safety of patients in England. 2013. Available at https://www.gov.uk/government/publications/berwick-review-into-patient-safety [verified September 2013]
[11] Skinner CA, Braithwaite J, Frankum B, Kerridge RK, Goulston KJ. Reforming New South Wales public hospitals: an assessment of the Garling inquiry. Med J Aust 2009; 190 78–9.
| 19236293PubMed |
[12] The King’s Fund. Our response to the final report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. Media release 6 February 2013. Available at http://www.kingsfund.org.uk/press/press-releases/our-response-final-report-mid-staffordshire-nhs-foundation-trust-public-inquiry [verified September 2013]
[13] Pronovost P, Wachter R. Progress in patient safety: a glass fuller than it seems. Am J Med Qual 2013;
| Progress in patient safety: a glass fuller than it seems.Crossref | GoogleScholarGoogle Scholar | 24249836PubMed |
[14] Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a safer health system. Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC: National Academy Press; 2000. Available at http://www.nap.edu/openbook.php?record_id=9728&page=R1 [verified September 2013]
[15] Crossing the Quality Chasm. A new health system for the 21st century. Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC: National Academy Press; 2001. Available at http://www.nap.edu/openbook.php?isbn=0309072808 [verified September 2013]
[16] Van Der Weyden MB. In the wake of the Garling inquiry into New South Wales public hospitals: a change of cultures. Med J Aust 2009; 190 51–2.
| 19236285PubMed |
[17] Berwick D. Letter to the people of England. 2013. Available at https://www.gov.uk/government/publications/berwick-review-into-patient-safety [verified September 2013]
