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A policy can be described as a declaration of intention, or a course or principle for action.
Australia’s national policy on health care is managed by the Australian government. Some key elements, like the operation of hospitals, are handled by state governments (DHHS 2016).
The Australian Government holds the primary responsibility for public and community health.
The Department of Health and Human Services is responsible for this in Victoria.
Their mission is to “aspire to see all Victorians healthy, safe, and able live a life that they love”.
They provide policies, programs, and services to improve the health and well-being of all Victorians (DHHS, 2016).
A cluster of perinatal death that occurred at Djerriwarrh Health Services between 2013 and 2014 was brought to the Department of Health and Human Services’ (the department) attention by the Consultative Council on Obstetric and Paediatric Mortality and Morbidity.
After seven deaths could have been avoided, the Australian Commission on Safety and Quality in Health Care performed an independent review of the department’s actions in relation these deaths and assessed the department’s ability to detect and address emerging critical issues in our public health system.
After an evaluation, the ACSQHC found significant problems and concluded that Djerriwarrh was not the case. Even worse, the processes of the department were incapable of detecting these issues.
These findings led the Minister of Health to request that Dr Stephen Duckett reviews the matter.
Check out the current systems used by the department to ensure quality and safety in hospitals.
If systems are found to be inefficient, to offer suggestions for how they can be improved.
These incidents, despite their being at Djerriwarrh Health Service, are seen as symptoms of a bigger problem.
The comprehensive, informative and thorough review will have an impact on all hospital and health-care services.
Many recommendations have been made and they are a call for serious changes.
The department’s supervision of hospitals is inadequate, according to the findings.
The department lacks the information necessary to assure the Minister (DHHS, 2016) that all hospitals provide high-quality and consistent care.
This review identifies and addresses the major problems in health care, as well as the related NSQHS:
1.Failure of reporting errors and adverse patient incidents.
This was revealed by the discovery that the department does not have a functional system for hospital staff members to report patient harm (DHHS 2016, p13).
One of the complaints about the system is that it is complicated to use, poorly designed, and too complex.
The “incident classification” component of the system currently contains more than 1400 types. This makes it difficult and complicated to choose the right classification.
This means that users can incorrectly classify incidents or choose generic classifications like “other” to save time. (DHHS, 2016 p107).
It was discovered that not all Djerriwarrh tragedies reports were made on time and accurately.
Nevertheless, it was discovered that the department didn’t monitor or analyse the incident database so they wouldn’t have been detected (DHHS, 2016).
“A dysfunctional incident-reporting system means that potentially useful data about recurrent safety breaches are often not reported, misclassified or lost prior to it reaching the department.” (DHHS, 2016 p14).
The “departments performance monitor framework” was not created to detect catastrophic failures, according to DHHS (2016).
This is the NSQHS to which this major defect relates. It is standard number 1 ‘Governance for Safety and Quality in Health Service Organisations’. (NSQHS, 2012.
For this particular standard to be achieved, certain criteria must be met.
One of those criteria is incident and complaint management. This means that adverse events must be identified, reported, and analysed.
Djerriwarrh and the department have not met this requirement effectively, as evident by the identified deficiency.
2. The department’s expert panels are scattered and not well-equipped to spot potential problems quickly or follow up to prevent them from happening again (DHHS 2016, 2016).
DHHS (2016) identified additional cultural barriers to reporting.
Staff complaints were often ignored or dismissed, and discouraged.
It was also found out that both regulatory oversight and internal management failed to spot the problem or didn’t address it (DHHS, 2016).
This NSQHS is standard number 1. It refers to standard number 1 – Governance for Safety and Quality in Health Service Organisations.
In relation to this particular standard, the specific criterion that was broken is incident and complaints management.
It is obvious that patient safety and quality incidents weren’t reported properly, analysed, or used to improve safety system (NSQHS, 2012). Miller, 2013.
3. The department has relied on accreditation too much when there is no evidence to support that claim (DHHS, 2016).
Djerriwarrh Health Services for instance, which was consistently recognized as a high performing department at the end 2012-13, received top scores until early 2015. Seven potentially preventable deaths were then discovered to have occurred at that time.
This failure was caused by a number of factors, but poor clinical governance is the primary reason. The department relied too heavily on accreditation.
This clinical governance failure at Djerriwarrh was a worrying sign. It could have easily happened at any other hospital or health care service (DHHS, 2016).
This is the NSQHS standard number 1 ‘Governance For Safety and Quality in Health Service Organisations’.
The standard requires that certain criteria be met to attain this standard.
One of the criteria states that a governance system must be in place to conduct regular clinical audits.
This is clearly not working as regular audits would have identified the problem in clinical governance.
4.The department has not used routine data collected to monitor hospital complication rates (DHHS 2016, 4).
Because essential data is not being collected or is not readily available, hospitals and clinicians are unable to access crucial information.
The department also has access to a lot of routine data, but it is not accessed often enough to monitor patient outcomes or look into red flags.
The department hasn’t been able access or use all the information it needs to monitor patient outcomes and investigate red flags.
This defect is due to NSQHS standard #1 ‘Governance For Safety and Quality in Health Service Organisations’. (NSQHS (2012)
The standard’s criterion is governance and quality improvement systems. It states that integrated governance systems must exist to manage quality and patient safety (NSQHS 2012).
Evidently, this is a failure by the department. Red flags and cases involving underperformance went unnoticed, putting patients at risk.
5. In the public service, the department depends too heavily on hospital boards in order to provide safe and quality care (DHHS, 2016).
The department does not adequately ensure that all boards are properly equipped to carry out this function (DHHS, 2016,).
This is a sign that the department’s oversight of hospitals is insufficient.
It was found that the department didn’t give enough importance to patient safety.
This essay will not address the disparities between hospitals boards of small and large hospitals. It also discusses the differing views of CEOs, financial teams and CEOs.
It was clear that the department did not do enough to get involved, understand, or even pick up these disparities. This is at the expense patient safety and continuous improvement of health care.
This defect is due to NSQHS standard #1 ‘Governance For Safety and Quality in Health Service Organisations’. (NSQHS, 2012).
Two criteria are required to meet this standard.
The first is the one regarding governance and quality improvements systems.
In this regard, integrated governance systems that actively manage quality risks and patient safety have clearly been broken.
In addition, the criterion regarding incident and complaint management has been violated. Patients safety incidents are not recognized, reported, and analysed at all levels in the healthcare system.
6.Similarly to point 6, the department in the private sector relies more heavily on local governance, i.e.
Hospital boards) to ensure safety and improvement of care (DHHS 2016, 2016).
The private sector also revealed that there is no routine monitoring of patient outcomes, or serious incidents (DHHS 2016).
Private hospitals are not required to report as public hospitals. As such, they do not receive the same reporting requirements.
This deficiency refers to standard number 1 ‘Governance For Safety and Quality in Health Service Organisations’ (NSQHS (2012)).
As with point six, two criteria required to meet this standard are broken.
The first is governance systems and quality improvement systems. The second is incident management and complaints management (NSQHS (2012)).
The department should do more in both these sectors to ensure that hospitals are not able to provide care (DHHS 2016).
7.The department hasn’t been supportive enough to hospitals and hasn’t provided sufficient leadership in safety and quality improvement (DHHS 2016, 2016).
It was discovered that the department had not provided the required support or sustained investment in the right equipment for hospitals.
Hospitals are often left to devise their own approaches to safety and quality improvements, which leads to duplication of effort, variation in quality, inefficiency, and inefficiency (DHHS 2016, 2016).
Hospitals are unable to share high-quality information and, therefore, cannot learn from each other.
In the end, the department doesn’t offer strong enough systems and does not provide the necessary information and incentives to hospital executives and clinicians in order to give the best possible care.
A lack of communication between the department and external expert bodies regarding the sharing information and, most importantly, the identification of unsafe practitioners was discovered (DHHS, 2016).
To meet this standard, two criteria must be met.
The first is “clinical practice”.
This criterion requires that clinicians provide care that is consistent with current best practice.
It is clear that if hospitals do not share high-quality information between hospitals, it is unlikely that all clinicians will be operating according to current best practice.
The second criterion was breached is governance & Quality Improvement Systems’ (NSQHS, 2012).
This criterion says that “there must be integrated systems for governance to actively manage patients safety and quality risks.”
Inefficient governance of the departments in terms providing resources for hospitals and clinicians is a result.
It is probable that the deficiencies of the department relate to all current NSQHS standard.
These include preventing healthcare-associated infections, medication safety and clinical handover, blood and product safety, preventing and managing pressure injury, recognising clinical deterioration in acute care, and preventing falls.
All of these issues boil down to a lack of clinical governance.
“Clinical governance” is the system and process that ensures that healthcare services are accountable to the community.
The review showed that Djerriwarrh’s and all other hospitals’ processes failed to detect significant weaknesses in clinical governance.
These problems and shortcomings in clinical governance aren’t just a problem for Victoria.
The literature review identified many articles that described similar problems in health care systems relating clinical governance, quality, and safety patient care (Atsalos, O’Brien, & Jackson,2007; Robinson, Travaglia, & Branithwaite,2008; Tuan,2015).
Duckett (2008) suggests that Victoria’s health care system is not in need of major reform.
It is however acknowledged that significant changes are required at both a macro level within the roles of Commonwealth governments and state governments as well as at a micro level among health care providers (Duckett 2008).
Part two: Change Management
From the review of Stephen Duckett, it is evident that major changes within the department are urgently needed.
Change is an essential part of health care.
Both external and internal factors can influence change. Organizations must adapt to the new realities and be aligned with them (Kumar Kumar Deshmukh & Adhish (2015)).
Technology advances, quality assurance and the emerging and reemergence of disease, as well as the eras of evidence-based policies, health and medical services, privatisation and business interests, and health rights (Kumar et. al. 2015).
In conclusion, adapting to changing conditions is essential for any organisation to survive.
Implementing and sustaining change is hard, especially if it’s not something you can do consistently.
Organizational change “requires personal changes in an organisational setting” Carlopio, Andrewartha (2008).
People are often resistant to personal transformation.
It takes persistence, time, and effort.
Sometimes there is a feeling of loss as the old ways of doing something become obsolete. But with change, we adapt and learn.
Research has shown that healthcare workers often face difficulties in successfully implementing change (Allen, 2016).
These problems include difficulties motivating employees to make changes, communicating the need for it effectively, and maintaining the improvements over time. Martin, Weaver, & Currie (2012).
It is recognized that the most challenging part of making changes in the health care system is the complexity (Allen, 2016).
Micro and macro change are two types of change.
Concerning health care and the Victorian Health Care System, macro change could refer to an overall change in the system or at an organizational level.
Micro change can be referred to a particular work unit or department.
For the Victorian health care system macro change is necessary at the whole health care system level. It starts with the department.
This will hopefully have a ripple effect down to micro changes in service delivery, bedside care.
These changes, however, require effective change management (Currie & Loftus Hills, 2002; Kumar et.al., 2015).
If nurses and other health professionals know about theories and models for change, this will increase the probability that organisational changes will be successful (Mitchell (2013); Price (2008)).
This is particularly important for managers and leaders in the health care sector, since these people will be most likely to implement and initiate the change.
There are many theories you can use to implement organisational changes (Allen, 2016 and Freshwater 2014).
However, there are only two models that seem to be the most effective for implementing changes in health care.
Modern theories and models are based on Kurt Lewin (1947), and his three stage model of change.
John Kotter (1996) created an 8-step model that is based on Lewin’s 3 step process. It has been successful (Kumar, et al. 2015).
These models can be summarized below. However Kotter’s 1996 model (which is based on Lewin’s three-step process) will provide guidance for readers as to how to improve the reporting culture of wards that are based around safety.