Now available online is a review of the management of a critical issue at Djerriwarrh Health Service (Bacchus Marsh Hospital) by the Victorian Department of Health and Human Services.
The review was undertaken the Australian Commission on Safety and Quality in Health Care. Of particular interest is the focus on whether there were early warning signs and the Department’s capacity to detect the emergence of critical performance issues in hospitals.
Six recommendations were made, which were accepted by the Department. An action plan response has been developed. Broadly the recommendations relate to:
- Strengthening the performance review role;
- Improving incident reporting and monitoring;
- Enhancement of maternity reporting.
The recommendations in full were as follows.
Recommendation 1: The department strengthen its performance review role of local health services by enhancing and strengthening its monitoring of clinical governance including auditing the effectiveness of, and compliance with, the Clinical Governance Framework in health services. As in the Djerriwarrh Health Services case, rural regional departmental staff are currently responsible for monitoring performance, including safety and quality. Consideration should be given to ensuring they have both the capability and management reporting lines consistent with this responsibility.
Recommendation 2: The department continue to develop the framework, procedures, tools and information available to regional offices for monitoring clinical safety and quality in local health services, including reporting by local health services to their boards of management as detailed under the performance framework to the department.
Recommendation 3: The department improve its capacity to meaningfully interrogate reports of incidents with Incident Severity Ratings (ISR) 1 and 2, and consider reviewing its list of sentinel events to include unexpected intra-partum stillbirth, term or near term perinatal deaths where the cause was unexpected and other serious adverse clinical outcomes were involved.
Recommendation 4: The department review the effectiveness of its incident reporting system including the nature of incidents required to be reported and investigated, and investigate its options to strengthen its information systems so that, as far as possible, incident reports can be systematically analysed and relevant clinical information be appropriately disseminated.
Recommendation 5: The department provide the Gestation Standardised Perinatal Mortality Ratio to all health service boards as recommended by Professor Euan Wallace in his Report of an Investigation into Perinatal Outcomes at Djerriwarrh Health Services, 31 May 2015, page 13, paragraph 5.2.
Recommendation 6: As part of strengthening its role in monitoring and auditing clinical governance in local health services in accord with recommendations 1 and 2, the department could consider developing guidelines on its powers to monitor the performance of health services and the circumstances where their exercise is appropriate.