'Beyond Bricks and Mortar - Building Quality Clinical Cancer Services' Symposium 2011
Panel Discussion: What Determines Quality Health Care & How can we Measure it? - Dr Michael Harrison, Associate Professor Rosemary Knight, Associate Professor Christopher Milross, Ms Sue Sinclair, Professor Margaret Banks
Introduction by Norman Swan:
I might just invite our panel up while we're just finishing off the chat with Michael. Our panel for this is Rosemary Knight, Principal Adviser, Population Health Division, Department of Health and Ageing; Chris Milross, Chair of the Tripartite Committee and Dean of the Faculty; Sue Sinclair, General Manager of Service Delivery & Clinical Practice, Cancer Australia; and Margaret Banks who is secr- Senior, not secret, Program Adviser, Australian Commission on Safety and Quality in Health Care.
Any points for Michael before we move on? Because one of the key questions for you is, is that where you're going to push for radiation oncology? Mandatory system - you don't get Medicare unless you do it. What it means is ... you answer, go ahead Chris, I'm glad to take the heat off me. Can we get the microphones up here?
Assoc. Prof. Chris Milross:
[inaudible until microphone arrives] .. about the maturation and development of the system and the standards with time. For example, the number of standards that are measured, presumably a much larger number in 2011 than it was in 1986.
Norman Swan:
I'm not sure we're getting much volume off these mics.
Dr Michael Harrison:
Ah yes, that's right. In fact when the first impact standards were released, most of the clauses were not requirements, they were lower level than that so in fact most of the documents were full of shoulds and mays rather than musts. But over time that has changed and most of the things that we would all agree on are essential to be done in all laboratories are all mandatory now. So that, it wasn't just the fact that from 1986 you couldn't get Medicare benefits unless you were accredited, it was the fact that the standards actually did evolve over time and the requirements did get more prescriptive over that time.
Ass. Prof. Chris Milross
I think that's a really important point for us, beginning that next stage.
Dr Michael Harrison:
Yes. I think the view that they're aspirational is good. So I think they did recognise the fact that there was going to be a period of time in which laboratories took to get to that point and in that time they weren't going to exclude people from accreditation while they were in evolution.
Norman Swan:
So we've asked the Panel a question, you can see it up there on the board, which is What determines quality health care and how can we measure it? Michael has told us that in quite interesting detail. Margaret, you're increasingly going to be the rule setter in this game, that's what the Commonwealth (inaudible) your role under health care reform. What do you think? Or what does your organisation think about the answers to these questions?
Prof. Margaret Banks:
It is determined by a number of things. I would say it's determined by the outcome. It's determined by asking consumers what it is that they think the quality of health care is because their definition of health care is different to our definition of health care and safety and quality is - there they set different parameters. How do you determine it? It has to be measurable and you need to be able to say the outcome looks like this and the outcome consistently looks like this.
Norman Swan:
But increasingly, in this area, both in Pathology and in Radiation Oncology, the outcome is as much the process. You know from randomized trials or whatever that this form of radiotherapy works and this, you know, and do you deliver that according to the evidence for example rather than the outcome which is probably in the lap of the gods often.
Prof. Margaret Banks:
But you've asked what determines it. Who determines it is a whole stack of people. What determines safety and quality is how do we want care provided? At what level do we want care provided? You're talking about pathology accreditation and I started with a role that said "Here is accreditation". I work through a place that said "Is accreditation the only way to test safety and quality?" and I think it's not. I think that it is one way of determining some factors about safety and quality but I think there's probably other ways to determine safety and quality around specific things. Accreditation gives you an overview but it is quite a blunt instrument if you are trying to look for a specific problem in your organisation. So like an infection, that it's no good doing it on a three-yearly or 18 month basis, because by then you've spread the problem and it's exacerbated or ...
Norman Swan:
But a part of your accreditation is having robust quality systems and fast responses. Surely that meets that requirement that you're actually going to be responsive to adverse events and do a cross-analysis or what have you?
Prof. Margaret Banks:
That's if your accreditation system includes that, yes. At the ISO framework that sits around NATA is sort of like that. It's a framework of quality and quality improvement. But not all of the accreditation systems out there that have that same structure around it.
Norman Swan:
Sue Sinclair, what's your take on the question and answer to questions here before you, and some of the things that Margaret might have been saying?
Ms Sue Sinclair:
Well from a Cancer Australia ...
[small interruption while moving microphone closer]
.... focus really on three levels and I think we'd like to see that quality health care occurs at the patient level, at the provider level and in a system-wide level. And I guess that was some of the areas that David Currow touched on yesterday, was ensuring that it was patient focussed but there was an all system approach. So we would like to see measurement at the patient level. What is it that consumer, advocates, patients, whatever we will call the group, and understand what their experience is and understand whether they received the right treatment. Was it as it was planned? And look at a core set of indicators that are consistent around best practice care.
Norman Swan:
So you can pull the levers in the public system, but if it's voluntary you can't pull the levers in the private system. And given that we're talking about a very large percentage of people in Australia going through private health care in oncology, how are you going to pull the levers to make sure that one in two patients with cancer, people with cancer in Australia, actually get the benefit of that framework?
Ms Sue Sinclair:
I think there are some levers in the private sector and certainly the health insurance bodies are the lever behind determining quality. They set the funding agreements with the private sector.
Norman Swan:
But there's no health insurance in radiation oncology.
Ms Sue Sinclair:
Right. That's true.
Norman Swan:
That's the point
Ms Sue Sinclair:
Yeah. Um ... lead by example. Demonstrate what we can that we know is occurring in the private sector because some registries do collect all data on radiotherapy. So certainly NSW does do that. So we can look at outcomes in a proportion and then build on that.
Normal Swan:
But there's no cancer registry that measures those (inaudible).
Ms Sue Sinclair:
No it doesn't at this point. So you can lead by example. There is no big stick as you say, as this point. That's certainly not where Cancer Australia would be focussing as the mandatory body. But we'd like to work with the collaborators around what is best practice and look at how we measure that an influence the system.
Norman Swan:
So the Commonwealth, Rosemary, would be quite - not the view from this side, speak for the Commonwealth and we accept that before you even open your mouth, but I mean is there - they would just like a soft namby-pamby sort of voluntary nice culture change system and that would be good enough for the Australian community?
Assoc. Prof. Rosemary Knight:
I'm going to answer that question in two ways. Firstly in relation to radiation oncology, the paper that you've got before you in terms of the standards it's the beginning of the conversation, so I think we're out for consultation, we're out to listen to hear about how it can be implemented, so I think it's very early days even though it's a great result and the standards are there. So that's one answer to it.
The second thing is I actually support what Sue's saying. I think there are levers and I think that they basically have three types. One is the professional groups themselves in terms of peer review and most, a lot of people work both in the private and public sector so I don't - I think we have to accept that there is in fact some crossover effect. The second thing is that I think that as part of the Health Reform Group we're actually looking at performance indicators and some of these features with Safety and Quality Commission, I think they have made a lot of good progress there. And thirdly I think more broadly, in terms of the kind of work that's being done at the jurisdictional level, I think we're getting a lot more data that's coming out in terms of outcomes which we will be able to map back to some of the different features and provider.
Norman Swan:
Except that we've heard at this conference that what's happening in the jurisdictions is all over the place.
Assoc. Prof. Rosemary Knight:
I'm not sure that it's all over the place. I think it's at different stages of development. I genuinely do. I think ....
Norman Swan:
How diplomatic.
Assoc. Prof. Rosemary Knight:
It's true. I think for example that Cancer Institute New South Wales has made a lot of progress. Some of the smaller jurisdictions have .. I mean Tasmania's just got some really good data in relation to their difference services. I think it's more that it's at variable points and I think it is progressing. I think - and Cancer Australia's got some good work underway to look at more comprehensive data systems.
Norman Swan:
Chris? Just bring that microphone a bit closer to you.
Assoc. Prof. Chris Milross:
Rosemary began by saying that the ...
Norman Swan:
Oh just before Chris goes on, this conversation includes you, so if I've irritated you, stand up and speak. Just come to the microphone and I'll bring you into the conversation as we go along. This is not just for the Panel.
Assoc. Prof. Chris Milross:
... that the issue's out for consultation and that's fantastic but I'll start by having a whinge and saying that the period of consultation is the 16th of September and if I look at my watch it's the 11th of August, and if I sit here as the Dean of the Faculty wanting to engage my profession and as the Chair of the Tripartite Committee to pull the opinions of the two other professional organisations together, that's not a very long period of time. And it's an important issue. And we know from the NATA review that this is an industry that has already bought into this idea. We want to do it. So that's a quick turnaround time for a very important topic.
Norman Swan:
So it will - how much wriggle room do we have on this?
Abel MacDonald:
I think there's two comments I'd make in relation to that The first is the discussion with the quality working group has been we could have ... that we would have a two phase process. One was to first seek the general opinions of the stakeholders. And once we have some general opinions in, we will sit down and look at perhaps three or four different models that may work for this profession and then do some more detailed analysis on the costs associated with those options. So it is intended to be a two phase process and this first phase is just to get some initial feedback from the professions and states and territories, private providers, the whole lot, on what they think might be options that could work so that we can then do that detailed cost analysis. Because certainly from a Commonwealth perspective, if a regulatory option is chosen, the regulatory impact analysis needs to take place. But what's the point in doing that if we're not going to go down a regulation option?
The second thing is that if the issue can be raised with the Chair of the Quality Working Group, heaven forbid, if we think we need longer time to do this first round of gathering what might be the contributions to options.
Assoc. Prof. Chris Milross:
We'll take that difficulty as an opportunity though (laughs). I mean I'm happy to start there.
Norman Swan:
So where do you sit on this just personally rather than as the Dean of the Faculty, given that - I mean I was being deliberately provocative obviously with Margaret, but the issue here is that you don't create a level playing field when you go the voluntary option. It sounds good, but the good places will do it well and the bad places, there may not be that many bad places, but we have had some examples of very large numbers of people getting underdosed and overdosed in Australia with significant consequences. They don't necessarily follow suit.
Assoc. Prof. Chris Milross:
Personally my view is something like the Nike phrase that I used yesterday, you know, "Just do it". And if that involves a legislative mandate and a funded method and setting up, using an organisation such as NATA to help us with the accreditation process and the College developing its own internal resources to do with that, bring it on. You know, I think it's all good.
So in picking up on those two questions, you know, What determines quality health care? In my mind, the quality standards and a system for measuring the extent to which people meet those standards and improve their practice based on those results, it's kind of just one part of it. It's a really important part but there's a whole lot more in my view that represents the determinants of a quality radiation oncology service and some of those things are much less tangible than 16 neatly thought out quality standards.
Norman Swan:
Such as?
Assoc. Prof. Chris Milross:
Well I mean some of them are quite tangible like assessment of clinical indicators, you know, you can do the traditional outcome measures, you know, local control and survival rates, morbidity and toxicity data. But some of them represent the design of comprehensive integrative patients and cancer services. And they're all words that Rosemary used today but I had already written down on the page as really important parts to a quality service. And how do you measure some of those things? Well that's actually quite a bit more difficult again. You can do it directly through asking the patients what they think of the service that we provided. You can do it through publishing departments, clinical trial rates or publication rates and Michael spoke about a bunch of that stuff earlier on today.
You can do it indirectly through looking at workforce measures like staff turnover rate? You know, are we an industry that people want to be in, come in and stay in? But those are not quite as concrete as "Have you reached this quality standard?"
Norman Swan:
Which is of course one of your aims here in Cancer Australia is to get those integrated coordinated services.
Michael, what are the costs involved? Have you assessed that?
Dr Michael Harrison:
It is hard. I'd estimate in my practice the direct costs of accreditation application fees and quality assurance program fees is about 0.3% of revenue. But the if you add all the other costs on top of that, the actual costs of the staff involved in the assessments, most pathology laboratories have got quality officers. And then if you want to add all the other quality activities which includes quality control and things like that, it probably comes up to several percent. So it's not insignificant.
Norman Swan:
Under five percent? Over five percent?
Dr Michael Harrison:
I think it's probably under five percent, yeah.
Norman Swan:
Rosemary, where - I mean is the Commonwealth going to be just advised by the industry here or will the Commonwealth take a position?
Assoc. Prof. Rosemary Knight:
Oh I mean I think that it's genuinely the case that the Commonwealth at the moment is going out there seeking indications. But I mean I think we should say that this is not the only field where the Commonwealth's been involved in, you know, sort of looking at standards and compliances. I mean I happen to be at the moment the interim Chair of the Breast Screen Accreditation Review Committee and I think we're struggling with similar sort of issues and that's a more mature program. I think it depends a bit on whether you're just starting on that journey or whether you're more mature. And some of the features really, sometimes I think it goes back to the Donabedian sort of notion about structure, process and outcome.
But I think one of the most important principles or threshold issues around quality, I mean cancer's potentially a life-threatening disease, is about do no harm. And therefore it's about making sure that we do get, you know, sort of not only, I mean we've just established that there are people in this room better able to talk about it than me, but the clinical dosimetry work that's being done by Abel's team and a lot of people in this room, but it's also about reporting adverse effects, it's also about looking at some of the systems' improvements and I think it's about a systems improvement sort of framework and that kind of approach. And even if - I mean I agree with Chris. Even if you have standards accreditation mandatory type reporting, it's about engendering a culture in terms of that support for a systems improvement approach. And I don't think that's about government mandating those things or being part of that. I think it's about often push from patient advocates.
Norman Swan:
Which is something I wanted to bring up with you Michael. I mean the implication for ...
Assoc. Prof. Rosemary Knight:
And with us?
Norman Swan:
Sorry, what ...?
Assoc. Prof. Rosemary Knight:
No. I'm finished.
Norman Swan:
The implication where you were saying is that in fact the proportion of problematic labs seems to have remained the same, through all these years.
Dr Michael Harrison:
Yeah I think it probably has. I think ....
Norman Swan:
Has the identity of the labs changed?
Dr Michael Harrison:
Ah, some have and some haven't. You'll see laboratories that have a good accreditation history who go off and it's usually due to poor supervision, so loss of key personnel, pathologists and scientists. Sometime its change of ownership. Often labs that are regularly poor performers dramatically improve when they're actually acquired by another laboratory.
Norman Swan:
I mean I suppose some of the implications you were just - hold on a second before you go down the mandatory road, is whether or not this is done in a grudging way or it is an opportunity for improvement and I suppose you can't generalise there but in some labs it will be done in a grudging way.
Dr Michael Harrison:
Yeah, see it's really hard to say. I really think having sanction at the end is very useful, both from the whole system so the government that's paying the bills and the population in general can be assured that there's acceptable standards is one thing. But also if you're trying to actually run your own organisation you know that people are going to have these sorts of activities assessed at some stage and if they don't do them then there will be a sanction involved from that perspective as well.
Norman Swan:
And I suppose it's people also realising that if things go bad, somebody will find out eventually ...
Dr Michael Harrison:
Yes.
Norman Swan:
... and there's a corporate risk here if you don't do it properly.
Dr Michael Harrison:
Yeah. There is nowhere to hide. And even though theoretically the assessment cycle is three yearly, there's a lot of activity that has to go on all the time, has to documented that will be discovered at that interval.
Norman Swan:
Yes.
Chris Hamilton:
Chris Hamilton here from Olivia Newton John, in relation to the question ...
Norman Swan:
How is she?
Chris Hamilton:
Oh, getting very physical these days. Look the people who know me know that I'm passionate about all the themes that have been brought up today and I support many of the comments that have come, but I want to inject a little bit of scientific validity here.
Norman Swan:
Wash your mouth out!
Chris Hamilton:
I'm sorry. Trialists in medicine around the world will laugh at the data and conclusions we and quality people make. They're soft. Not unimportant, incredibly important but soft. All the major intergroup trials in cancer and in particular TROG have massive amounts of hidden work behind the scenes around quality. These never come to air, they're buried in fairly boring publications. But if you participate in a good trial structure as a department in Kickatinalong or in Melbourne. Wherever you are, and you're participating in trials and those trails are QA'd, for free., you get a quality program. And a top notch quality program. So if your trial participation rate is 5%, Abel and the Feds and everyone is getting for free a quality program. It is one of the best surrogate endpoints of quality It's not the only one, but it's one of the best that you'll get. Absolutely.
Norman Swan:
Want to comment Chris?
Assoc. Prof. Chris Milross:
I mean I agree completely with that, you know, in recruiting patients to clinical trials without suggesting for a moment that any coercion would be involved. A comment that I often make is that one of the best things about this is that somebody else checks what I do against a pre-defined set of standards, you know, And I agree with Chris. It's quality assurance for free.
Assoc. Prof. Rosemary Knight:
It's one of the reasons why we put in the regional cancer centres that the regional cancer centres have to wherever possible participate in research and do clinical trials. I think it's a little bit difficult sometimes for some places that are more remote or rural but nonetheless, I agree complete with Chris and I think it's supported by the work that Cancer Australia's done to try and improve trials.
Norman Swan:
Before I came to Ian, Margaret how much granularity will the Commission come down to or is it just going to be setting this high level principle stuff?
Prof. Margaret Banks:
High level principle stuff. And in fact when I looked at that list of issues that NATA had identified, maybe three or four of them sit within our standards. So clinical handover, patient identification or identification of all things related to the patient, recognising and responding to those deterioration and doing something about it, so what mechanisms do you have in place? They were all there. They are there at a high level. And the standards, the safety and quality standards have been written to provide basically a core, a framework onto which areas such as this could add detail by say there is something in Infection Control that you wanted to add detail to, you could be more specific and add them within a standard, or you could add to the Standards and make them a broader set of standards. But we do see these standards sitting in as a core because so much of what they require is fundamental to all care.
Norman Swan:
So you're setting the bar lower to start with.
Prof. Margaret Banks:
Well they've been described as minimum standards, absolutely. That's how they've been described. But when we talked to consumers, we talked about the level of care that we expect and when I say "minimum standards", the pilots that we've done, services that usually fly through their accreditation, have had difficulty meeting some of the requirements. So yes, they're minimum standards. That's the minimum we expect to provide. But I don't think it's exactly at the level ...
Norman Swan:
It's not trivial.
Prof. Margaret Banks:
No.
Norman Swan:
Yep. Ian?
Ian:
Good. A number of mentions have been made about consumers and patient advocates. I'd like to give a few warnings actually. And these are very consistent with the National framework on consumer involvement in cancer control, because how to get the views of consumers is actually not straight forward. Having an articulate consumer on a committee might look good. But that articulate consumer should be able to establish that they are in fact representing the views of other people and are connected, well connected, with average consumers. And unfortunately not all of us pass that test.
Just having a token consumer on a committee is not consumer consultation. Using patient satisfaction surveys on exit is a waste of time. Because a high halo effect operates. And it can be a negative halo or a positive halo. If it's a negative one they've had a really bad experience, they might tell you. But most people, they've been there, they think they're cured, they're really grateful to the system and so they will give you glowing reports.
There are very good patient and carer experience instruments out there. And they should be being used. There are some that have been developed within Australia, specifically for Australian conditions. But the difficulty here is that when you collect that patient and carer experience, which I suggest you do by using registry samples and doing at a fixed time point after the end of diagnosis or treatment, you have to benchmark them against something. And that becomes another thing. What are you benchmarking them against? We do have good clinical practice guidelines. We do in at least one jurisdiction have patient management frameworks. We do have standards. And from a good patient and carer experience survey, you can do that benchmarking and test very well how your health system is working. But it costs money. And so my question to the panel is how can we go to get funding to do such surveys?
Norman Swan:
Sue Sinclair?
Ms Sue Sinclair:
I was waiting for it (laughs). Well certainly Cancer Australia has funded patient experience surveys through CanNet. I think the question is also that we need to use the data. So we've actually done surveys in New South Wales every year for three years. We've done a national survey of over 2000 patients. We actually have to then apply that, feed that information back and include it in a performance improvement cycle. So I think there is adequate information out there to tell us what the experience is of patients. Now we've got to use that. Apply it to our service and think about how do we do things differently and have consumer focus groups, have consumers within the organisation, so that we're actually listening and hearing and continually improving.
Prof. Margaret Banks:
Norman if I may, the Commission's just released a document providing some tools and supports for organisations looking at engaging patients and consumers in their processes. This is more than the token committee person. I think having been through a process just recently to develop the guides for the National Standards which includes a patient participation standard with the requirement for consumer engagement as part of that, it is difficult for people to understand exactly what it is they're supposed to do. And so while we know from the research that patient participation is an important way of improving safety, we certainly haven't yet produced the tools broadly and applied them and been innovative about the tools. And so that research and that work in those tools are now just starting to come out.
Prof. Gill Duchesne:
Gill Duchesne again. Ian mentioned it and asked you how you'd find it. Chris mentioned it and said it was free. QA, quality control costs. I just want to float that one out there.
Norman Swan:
Well it's what you're in the business of doing. So it's part of the costs of business surely.
Assoc. Prof. Chris Milross:
Yep. I think that's true.
Norman Swan:
The question is whether your remuneration and your funding reflects that cost. I just want to move onto governance for a moment. Is the Commission neutral on governance when it comes to ...
Prof. Margaret Banks:
No. One of the first standard in the .. and one of the two overarching standards is governance.
Norman Swan:
But how, in other words when I say "neutral", I mean how it's done. Did you have a sense of what makes good governance rather than just saying "You've got to have a system of governance"?
Prof. Margaret Banks:
No, we've not been specific about what systems, mainly because the standards that we're writing have to apply to every setting of health care, you know, individual doctor practices and allied health practices right through to complex health care systems. It is difficult to be prescriptive in any way in these standards because of their audience.
Dr Michael Harrison:
Any quality systems accreditation will look at governance. It'll look at organisational structure and policies and whether they're consistently applied. So that's part of a standard accreditation process.
Prof. Margaret Banks:
But to be specific about how that should work in that setting is difficult when the standard needs to apply broadly across the whole system.
Norman Swan:
Just to clarify Michael, the government doesn't have a seat at the table of your accreditation system does it?
Dr Michael Harrison:
Not it doesn't.
Norman Swan:
So who should have a seat at the table in the Radiation Oncology governance, whether it's voluntary or mandatory, Chris?
Assoc. Prof. Chris Milross:
Good question. I think that there are some interesting parallels between radiation oncology as a complex business with lots of stakeholders and pathology, different professions, a whole range of public and private providers big and small. I'm cognisant though of the fact that by way of comparison, we're a smaller industry than pathology and that presents us with some real challenges I think. Personally, and I think most of the members of the Faculty would see our role very much as retaining a governance role in the oversight of an issue such as this and yet I'm not ignorant of the fact that there are some big challenges associated with that. So who are the stakeholders? We certainly are, the professions in the Tripartite Committee certainly are and I think in our infancy, starting on this journey, it makes sense to cooperate with other stakeholders that have got something to bring to the organisation including the Department and organisations such as NATA, as is outlined in the Options papers.
Norman Swan:
But I imagine government doesn't really want a seat at the table does it Rosemary? It doesn't want to be too close to it.
Assoc. Prof. Rosemary Knight:
Abel's there to answer that question.
Norman Swan:
Oh Abel?
Abel MacDonald:
Sorry I just can't help myself.
Norman Swan:
Good, good, good.
Abel MacDonald :
I think there's a couple of things that I'd say. Government is, in terms of the quality framework more broadly within ... somebody asked the question "Is government at the table in relation to accreditation and pathology?" Michael's right. They're not. In terms of the quality framework, is government at the table? Well yes they are. Because you have NPAAC, the National Pathology Accreditation Advisory Council, which government, all the professions and all the states and territories sit at, which has a role in setting the standards. So the standards is one element.
The conformity assessment or the accreditation is another element. So that's my first point.
My second point is I think what this discussion paper is trying to tease out, and which I think is really important that people in this room comment on, you'll find it, I think it's on about page 15 or 16 in the document, but it's a light coloured table through to a dark coloured table. Do we go a light touch? Do we go a heavy touch?
Norman Swan:
It's actually on page 26.
Abel MacDonald:
Oh thank you. So I think that's a really important consideration that people have to talk their mind, put their mind to and provide comment on. And with the light and heavy touch also comes the light and heavy cost. So that's another important factor I think that needs to be taken on.
And I think the last one that people need to ask themself is about the level of risk. So if there's a relatively small number of things going wrong, do you come in with a very heavy hammer - or sorry, I should say a heavy tool? So it's one of the questions that I think people have got to ask themselves. So I'm not prescribing an answer, I just want to encourage people to think about those elements of it.
Norman Swan:
Thanks Abel. I think what I might do now, I think it's appropriate that Leigh, I thank the Panel very much for their involvement, thank you Margaret for coming down. Sorry I gave you a hard time.
Prof. Margaret Banks:
That's alright.
Norman Swan:
... and so could you please join me in thanking the Panel, including Michael for such an excellent presentation.