Heather Buchan

THE CareTrack study published in this week’s MJA highlights a significant issue for the medical profession.

Some aspects of the study, such as the evidence base for a number of the indicators used and the relatively small numbers of patients and encounters, can be criticised. However, the general message — that a substantial number of people do not receive the most appropriate care for their condition — has been previously reported for a number of specific conditions in Australia and elsewhere.

Five years ago, a paper in the MJA noted that in Australian general practice only about half of patients with chronic diseases such as asthma, type 2 diabetes and hypertension received recommended care. The CareTrack study suggests that the overall picture in Australia differs little from other countries where similar studies have been undertaken.

The findings support the outcome of recent consultations by the Australian Commission on Safety and Quality in Health Care on key safety and quality challenges. Improving appropriateness of care was identified as an area needing coordinated national action and is one of the draft National Safety and Quality Health Care Goals to be considered by health ministers later this year.

National Safety and Quality Health Service (NSQHS) Standards developed by the Commission identify the processes and systems that acute health care organisations should have in place. A national accreditation system for all acute health services and day care centres based on these NSQHS Standards will be introduced over the coming year.

The Commission has also started to develop clinical care standards, with accompanying indicators, for a range of conditions, which will differ from the NSQHS Standards.

The standards will describe measurable aspects of care that should be offered or performed routinely — the usual care that most of us would want to be offered if we had the condition.

This does not prevent care being appropriately tailored for individuals but it does create an expectation that departures from the standard are documented and justified.

The MJA study identifies some of the problems with current guidelines and the Commission’s standards will be developed taking account of existing knowledge about features that are likely to improve uptake of guideline recommendations such as use of behaviourally specific language. There will be extensive consultation and the clinical care standards will be developed collaboratively with clinical experts and consumers.

The CareTrack authors highlight the need for routine, ongoing systematic performance monitoring. The capacity to measure the care that is delivered and monitor change underlies all improvement efforts.

It is unlikely that we will ever have a system that captures hundreds of indicators about care processes and outcomes, but we will be identifying some key performance indicators that can be collated and aggregated for reporting nationally with more detailed audit tools that can be used for local collection, feedback and improvement initiatives.

The ultimate challenge, however, is not in the development of standards and indicators (although that is no easy task). It is in finding ways to ensure that care that is known to be effective and appropriate is consistently practised.

We only have to look at handwashing — a practice that was shown to be of importance in preventing the spread of infection 150 years ago — to see how difficult it is to ensure that even simple actions are consistently and appropriately practised.

We are still expending significant resources and effort in an attempt to reach the hand hygiene benchmark rates of 70% in Australian hospitals, with hand hygiene compliance by nurses at 74% and by doctors at 52% after 2 years of the National Hand Hygiene Initiative.

While clinical care standards can identify the care that people should expect to receive, regardless of where they are treated within Australia, changing practice to achieve consistent delivery of appropriate care will require clinical leadership and system-wide coordinated action.

Dr Heather Buchan is the director of implementation support at the Australian Commission on Safety and Quality in Health Care and Professor Debora Picone, AM is the Commission’s Chief Executive Officer.

Posted 16 July 2012

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