Improving the system: One action at a time

In a 2013 televised address the Chief of the Australian Army, Lt. Gen. David Morrison, said ‘The standard you walk past is the standard you accept’.¹ While Morrison was talking about unacceptable behaviour in the Australian Army at the time, equally there are messages here for those who are involved in managing and leading health services. What is the standard of healthcare expected in Australia today? The alternative questions could be: What standards do we walk past in relation to patient safety and quality or compassionate care? or What standards do we walk past in terms of bridging the gap in Indigenous health disadvantage?, among others.

If there is a commitment to improving health care in Australia, the system can be viewed in terms of examining five interconnected elements: patients (or clients), processes, people, priorities and partnerships. Focussing on these five elements provides a framework to understand critical health service components if there is a desire to make systems improvement.

The revelations from the 2013 Francis Inquiry into the failings of the NHS Mid Staffordshire Trust are a case study of failing standards across the five elements, however what appeared to be the most telling were the reports of nursing care that were callous and uncaring. The Inquiry reported among other things ‘…call bells going unanswered, patients left lying in their own urine or excrement, or with food and drink out of reach’.² Tellingly, the ‘Trust was operating in an environment in which its leadership was expected to focus on financial issues, and there is little doubt that this is what it did. Sadly, it paid insufficient attention to the risks in relation to the quality of service delivery this entailed’³ (p. 45). Clearly, there was a lack of professional courage or an acceptance that the level of care that was being provided to those patients was good enough, which led to adverse patient outcomes and deaths. Surely these are standards that are unacceptable, but somehow they were overlooked, ignored or walked past.

Francis made the point in his executive summary ‘…there needs to be a relentless focus on the patients’ interests and the obligation to keep patients safe and protected from substandard care. This means that the patient must be first in everything that is done: there must be no tolerance of substandard care’³ (p.66). Improving the health system will require putting patients in the centre of all care and healthcare decisions, with processes, people, priorities and partnerships being critical elements to understand and actively manage.

Over the past 3 years an increasing emphasis on critical health service processes by the Australian Commission on Safety and Quality in Healthcare has seen the implementation of 10 core mandatory health service standards.⁴ These standards focus on organisational processes to ensure quality and safety in the patient experience. Even still in today’s healthcare system, with these standards and the available technology, we can still give the patient the wrong drug, undertake the wrong surgery or give a patient an infection through failing to undertake simple procedures such as handwashing. Processes are only as good as the people who implement them and it requires every member of the healthcare team to play a part in identifying, speaking up and not walking past when a process is breached. In TeamSTEPPS^® training to improve team communication and patient safety, every team member has ability to ‘stop the line’ if they sense or discover an essential safety breach.⁵ It is evident that we need more ‘stop the line’ moments to improve our healthcare system.

If patients are considered the centre of care, then staff are essential to make this happen. In addition to proactive workforce development and providing positive safe work cultures, the interactions of staff are critical if there is a commitment to patients’ interests. In 2008, Garling identified ‘…one impediment to good, safe care which infects the whole public hospital system. It is the breakdown of good working relations between clinicians and management which is very detrimental to patients’⁶ (p.11). Morrison aptly stated that ‘Every one of us is responsible for the culture and reputation of our [service] and the environment in which we work’.¹ At times it appears that patients become peripheral to health service operations as managers and clinicians have conflicting views on health system performance, activity, funding and delivery. The health system deserves and expects health professionals, both clinicians and managers, to work together for the patient, rather than each trying to wrestle control from the other. Every staff member must be working towards safe and quality care, not working against each other to the detriment of the patient. What standard should be expected of the health workforce, either in terms of creating positive, collaborative work cultures or working collectively to solve some of this country’s complex health issues? How can we expect to deliver safe, effective, patient centred care when the workforce is demoralised or culturally ‘bankrupt’? The Francis Inquiry clearly demonstrated the outcomes of a demoralised workforce on patient care, and this is a standard that cannot be walked past if there is a seriousness about improving the system.

Where do Australia’s health priorities lie and how does this impact on the type of health system we currently have. The current Federal Government has signalled its priorities with reduced funding for dental health; a move away from activity-based funding; reduced commitments to hospital funding by over $50 billion between 2017 and 2025; establishment of Primary Health Networks; and reviews of the Medicare Benefits Schedule, primary health funding and electronic health records, just to name a few. The extent to which these priorities put patients in the centre of care and improve access, equity and improved health outcomes must be assessed – what are we prepared to accept and what will we walk past?

Partnerships are critical to improving our health system, whether it is between Federal and State governments; different clinical groups; primary and secondary health services; health services and universities; clinicians and researchers; health organisations and consumer groups or Indigenous health initiatives. Every partnership takes trust, commitment and time. Are we prepared to walk past an opportunity to work in partnership to improve our healthcare system?

The appeal of this five-element approach is that it works equally well for the frontline caregiver as much as the hospital CEO or the Director-General of Health. Each and every front line clinician, support staff and manager can make a difference if they choose to make continuous, incremental improvements in their own practice area across these five elements. The personal commitment to improving the system in our own areas of influence starts with rejecting poor standards: poor standards of care; substandard communication; unworkable processes; misdirected priorities and lack of teamwork.

What did we do differently today than we did yesterday to make the health system better for tomorrow? What it takes is to not walk past one more poor standard, just one action at a time.

Professor Gary E. Day

Editor-in-Chief

Australian Health Review