Samantha was admitted to hospital recently. She had abdominal pain, anxiety, and a rash, and the tests suggested she needed exploratory surgery for her abdominal pain. She was understandably worried. Because of this and a couple of problems at work, life had got on top of her.
When a person like Sam is admitted to hospital, an enormous multifaceted system kicks into action. In fact, even before entering the hospital, a patient has often already been part of a complex web of care, including GPs, physios, pharmacists, and community nurses; along with the family and friends of the patient, who are integral to the caring system.
This complex system works incredibly well – most of the time. Yet, for one in ten people in hospital, something goes wrong. An incorrect dose of medicine is given, the wrong test is ordered, the procedure has a glitch or mishap or sometimes, tragically, a patient dies due to error. All these incidents, from the mundane to the catastrophic, are considered to be what we call “iatrogenic harm” and contribute to the stubborn statistic that 10 per cent of patients suffer at the hands of the system – especially when in hospital.
It’s time for a new way of thinking. What if we shifted our focus onto the nine in every ten patients entering the hospital who experience no harm?
That figure of 10 per cent has remained static for 25 years despite concerted efforts to reduce it. Many of these interventions have been incredibly valuable. For instance, Australia was the first country in the world to introduce a colour-coded system to visually indicate an inpatient’s deteriorating condition and thereby ensure elevated supervision and response. The overall rate of harm however remains seemingly set in stone.
Meaning that most of the time, the health system gets it right.
It’s time for a new way of thinking. What if we shifted our focus onto the nine in every ten patients entering the hospital who experience no harm? This is Sam, we hope, and of course many others. They go through their complex journey, receiving treatment and are released from hospital to go on with their lives. Meaning that most of the time, the health system gets it right. This approach does not ignore the times when things don’t go to plan, but rather acknowledges that a lot of the time, the system works well despite the complicated interactions of people, places, procedures, protocols, pills and pathology that occurs across health settings.
Well, we can ask: how come? We can learn from this. Instead of continually focusing on preventative measures in reaction to things that go wrong, we can look to why things go right, most of the time. By studying everyday clinical activities at the coalface, we can begin to understand how it is that great care is delivered successfully to more than 11 million Australians admitted to hospital every year, from small hospitals in the remote desert regions of Western Australia to bustling emergency department and delivery suites in Alice Springs, to those focused hospitals serving indigenous communities in Darwin and the Top End, to the biggest, shiniest teaching and referral hospitals such as the Royal Melbourne, Princess Alexandra in Brisbane, across to the Sydney Children’s hospitals, to the brand new Royal Adelaide, the St Vincent’s group of hospitals around the country, and Prince of Wales Hospital right in the heart of Sydney’s eastern suburbs.
Our research has shown that 60 per cent of care received by Australians – from children to the elderly – is in-line with current and appropriate medical practice. Guidelines have been developed for clinicians to deliver the best possible care and most of the time, patients receive it.
For the remaining 40 per cent, there is sometimes good reason for them to receive care that is different to what is considered best practice. For instance, if a person has been diagnosed with an infection but is allergic to the antibiotics that are the recommended treatment, a different and more tailored option will need to be found.
Our research has shown that a patient’s overall sense of wellbeing is improved when provided with easy-to-understand information and guidance upon admission and discharge.
But most people can be treated within the guidelines for best practice and ideally, we would like to revisit our study in five years times and find that 90 per cent of patients are receiving care in line with guidelines. That way, we would know Australians are receiving the best possible care and that health resources are not being wasted on treatments, tests and procedures that evidence has shown are not necessary. It’s the same for Samantha: she should get good care for her conditions: it should be the right care, the most up-to-date, evidence-based care.
Yet on the basis of our best estimates, at present in Australia and other developed countries, one third of resources within our health system are wasted. That sounds like a lot. Contributing to this statistic are antibiotics being prescribed unnecessarily, tests being ordered that are not appropriate, procedures that are not called for and hospital resources being used superfluously.
Our first-class health and medical training programs for clinicians, hospital administrators, allied health professionals and other healthcare workers support the health system to perform optimally and for the benefit of patients. When we stray too far from what we know – that is, evidence-based medicine and best practice, with patient preferences being understood and taken into account – then we can get harm and waste.
Everyday, our understanding of how to make the health system safer is bolstered by new ideas.
Our work in the Institute is showing that we can learn from what already works well and build on this. Our research suggests a handful of strategies can help:
- Demand a patient-centred health system: This should mean that people are encouraged to participate in decision-making about their care. Our research has shown that a patient’s overall sense of wellbeing is improved when provided with easy-to-understand information and guidance upon admission and discharge. Our studies have also shown the importance of recognising and responding to the feelings of residents in aged care facilities, in particular their feelings about friendship, love and contentment. The Choosing Wisely campaign across the world urging clinicians and patients to question things and think about the right care, asks for several things: Care should be supported by evidence; not duplicative of other tests or procedures already received; free from harm; and truly necessary. (http://www.choosingwisely.org/our-mission/).
- Integrate care: Patients should not have to explain the same symptoms five times to five different healthcare workers. Our research with the Sydney Children’s Hospital Network has shown the value of integrating a variety of services including GPs, specialists, physiotherapists and pharmacists in one place (physically or digitally) for the benefit of children with complex medical conditions.
- Try to keep healthy: Our population is not only ageing, but it is growing older with more diseases and conditions. We live longer but as we do there is always the risk of cancer, diabetes, heart conditions and depression. Preventative healthcare is one answer, which relies on people being able to access high quality information – and to eat well, exercise, get plenty of rest, reduce risky behaviours such as smoking and drinking more than is good for them – in short, to live a balanced life. AIHI is undertaking research to improve the safety of public health advice and affect the spread of misinformation, such as anti-vaccination myths. Meanwhile, Healthdirect Australia (https://www.healthdirect.gov.au/), another partner of ours, has a website and app that are reliable and safe, and provide excellent advice. This journal, too, and the Consumers Health Forum Australia provide access to information that is based on solid, accurate and relevant evidence.
- Make a difference: Everyday, our understanding of how to make the health system safer is bolstered by new ideas. The ability to implement these ideas into real-world settings must go hand-in-hand with this. Our National Health and Medical Research Council Centre of Research Excellence in Implementation Science in Oncology, for example, is leading the way in cancer care, figuring out how to translate breakthroughs into real world treatments.
Samantha got good care and was discharged back to her GP. Her procedure went well and resolved the problem. She was referred to a professional counsellor who was a great listener for her anxiety, and her rash began to resolve with an appropriate ointment from the GP.
Many patients receive care just like this. Our aim is to support such experiences through our research and make as many caring episodes as possible to be based on good practice with patients in the lead. It’s a complex system and Sam’s situation reminds us that every patient journey is unique and challenging, but we can learn about it together, and make healthcare work even better for everyone.
 Not her real name; based on an amalgam of people to protect privacy